Northgate Plaza

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 10 residents (Resident #9) reviewed medication administration, and for residents residing on two of four halls (Hall 100 and 200) reviewed for infection control The facility failed to ensure personal items were not stored on the medication carts located on the 100 and 200 halls on 03/31/2026.The facility failed to have staff sanitize hands after going from dirty to clean task before donning clean gloves and entered the resident room to administer medication. These failures could place residents at risk for infection. Findings included: During an interview and observation on 03/31/26 at 8:55 a.m., Medication Technician F was observed with a personal water bottle on top of the medication cart on 200 hall. She stated it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 23 residents (Resident #9) reviewed for hazards. The facility failed to ensure Resident #9 did not have a can disinfectant spray and a bottle of hand cleaner spray in his room on 03/31/26. This failure could prevent the residents from having an environment that was free from hazards.Findings included: During a Record review of Resident #9's Face Sheet, dated 03/31/26, revealed an [AGE] year-old male, admitted [DATE]. Resident #9 had a diagnosis of Dementia (a progressive loss of memory, reasoning and communication skills). During a Record review of Resident #9's MDS Assessment, dated 03/10/26, revealed the resident's BIMS was 7, which indicated severe cognitive impairment. The MDS Assessment reflected the resident had an active diagnosis of Dementia. During an observation on 03/31/26 at 10:45 a.m., Resident #9 was sitting in his wheelchair, a can…

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 care plans were developed with the resident and the resident's representative for 3 (Resident #3, Resident #7 and Resident #39) of 5 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #3, Resident #7 and Resident #39 or the resident's representative were invited to and participated in the resident's care plan meeting. This failure placed residents at risk for loss of independence, psychosocial well-being and the opportunity for them to participate in the planning of their care. Findings included: Record Review of Resident # 3's face sheet dated 03/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included COPD (a progressive but treatable lung disease that causes chronic air flow blockage) bipolar disorder (a mental health condition characterized by intense alternating mood swings), type II diabetes (a condition where the body resists insulin), depression 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, based on the comprehensive assessment of a resident, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #45) of three residents reviewed for quality of care. The facility failed to ensure skin integrity changes were documented for Resident #45. This failure placed residents at risk for skin integrity changes occurring with no monitoring in place. Findings included: Record review of Resident #45's quarterly MDS Assessment, dated 01/14/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's cognitive skills for daily decision making were severely impaired. The resident's diagnoses included traumatic brain dysfunction, quadriplegia (inability to move arms and legs), and seizure disorder. Record review of Resident #45's Comprehensive Care Plan, 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 was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #2) of three residents reviewed for Foley catheters. The facility failed to ensure LVN A performed catheter care for Resident #2 per facility policy. This failure placed residents with Foley catheters at increased risk of infection.Findings included: Record review of Resident #2's admission MDS Assessment, dated 12/27/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident had a BIMS score of 15 indicating the resident's cognition was intact. The resident had diagnoses including obstructive uropathy (blockage in the urinary system that impedes the normal flow of urine) and urinary tract infection. The resident had an indwelling catheter. Record review of Resident #2's Comprehensive Care Plan,…

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 for the facility's only kitchen. The facility failed to ensure food items in the facility's walk-in refrigerator were labeled and dated. These failures could affect residents who received their meals from the facility's only kitchen by placing them at risk for food-borne illness, and food contamination.Findings included: Observation on 03/10/2026 at 9:40 a.m. in the walk-in refrigerator revealed a package of hamburger patties and a container of brown gravy was not labeled and a package of chicken legs was not labeled or dated. In an interview on 03/11/2026 at 11:05 a.m., [NAME] C revealed that all items should be labeled and dated and that someone probably got in a hurry and forgot. She stated the risk to the residents is the food could get mixed up with something else or it could be expired. In an interview on 03/12/2026 at 10:02 a.m. the Dietician stated it was her expectation that everything be…

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 respect the residents right to personal privacy, for 1 of 4 residents (Resident #1) reviewed for privacy for medical treatment.LVN P conducted Resident #1's blood sugar test in the hall and not in a private setting.This deficient practice could place residents at risk of not feeling as if they were being treated with dignity, privacy, and respect. Findings include:Record review of Resident #1's Face Sheet, dated 01/13/26, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. t Diagnosis included Type 1 Diabetes Mellitus (high blood sugar).Record review of Resident #1's Quarterly MDS assessment, dated 12/30/25, reflected a severe cognitive impairment. Record review of Resident #1's Comprehensive Care Plan, dated 09/25/25, reflected the resident had Diabetes Mellitus and interventions included blood sugar checks per physician orders.Record review of Resident #1's Physician orders, dated 02/13/25, reflected Insulin…

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #2, Resident #3, and Resident #4) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light in Resident #2, Resident #3, and Resident #4's rooms were in a position that was accessible to the resident on 09/30/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #2 Record review of Resident #2's Face Sheet, dated 09/30/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a history of falling, unsteadiness of feet, and muscle weakness. Record review of Resident #2's Comprehensive MDS Assessment, dated 09/30/2025, reflected that the resident had severe impairment in cognition…

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 treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #2) of eight residents reviewed for resident rights. The facility failed to treat Resident #2 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his catheter bag (collects urine from the urinary bladder) on 09/30/2025. This failure could place residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.Findings included: Record review of Resident #2's Face Sheet, dated 09/30/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with urinary retention (inability to empty the bladder completely). Record review of Resident #2's Comprehensive MDS (assessment used to determine functional capabilities and health…

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 observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #2) two residents reviewed for catheter care. The facility failed to ensure that RN D placed orders for Resident #2's catheter when the resident was admitted back to the facility on [DATE]. This failure could place residents with catheter at risk of no continuity of catheter care.Findings included: Record review of Resident #2's Face Sheet, dated 09/30/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with urinary retention. Record review of Resident #2's Comprehensive MDS Assessment, dated 09/30/2025, reflected that the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #5) of five residents reviewed for respiratory care. The facility failed to ensure Resident #5's breathing mask was stored properly when not in use on 08/12/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #5's face sheet, dated 09/30/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #5's Quarterly MDS Assessment, dated 09/15/2025, reflected 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, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #1) of ten residents reviewed for medication storage. The facility failed to ensure Resident #1's skin protectant (medicated cream used to prevent skin irritation) was not left inside the resident's room on 09/30/2025. This failure could place residents at risk of misuse of medications that could lead to overdosing and adverse reactions.Findings include: Record review of Resident #1's Face Sheet, dated 09/30/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with soft tissue disorder (variety of conditions that affect muscles and tendons leading to pain and swelling). Record review of Resident #1's Comprehensive MDS Assessment, dated 08/24/2025, reflected the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 (Resident #2) of eight residents reviewed for infection control. The facility failed to ensure CNA C wore a gown while providing incontinent care to Resident #2, who had a catheter (flexible tube inserted into the bladder to remove the urine) and had an order for enhanced barrier protection, on 09/30/2025. This failure could place residents at risk of cross-contamination and development of infections.Findings included: Record review of Resident #2's Face Sheet, dated 09/30/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with urinary retention. Record review of Resident #2's Comprehensive MDS Assessment, dated 09/30/2025, reflected that the resident had severe…

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 residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents.The facility failed to ensure Resident #1, assessed as high fall risk, had a floor mat in place while in bed upon observation on 08/07/2025 at 10:53 AM and 11:43 AM. This failure could place residents at risk of injury, resulting in a decreased quality of life.Findings included:In record review of Resident #1's Face Sheet dated 08/07/2025 revealed he was a [AGE] year-old admitted from an acute care hospital on [DATE]. Relevant diagnoses included traumatic brain injury (outside force/injury to the brain,) major depressive disorder (persistent feeling of sadness and loss of interest,) and repeated falls. In record review of Resident #1's Quarterly MDS dated [DATE] revealed he was moderately impaired cognitively with a BIMS score of 08. Resident #1 required substantial/maximal staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of six residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms was in a position that was accessible to the residents on 05/14/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: 1. Record review of Resident #1's Face Sheet, dated 05/14/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included repeated falls, and seizures. Record review of Resident #1's Quarterly MDS assessment, dated 02/11/25, reflected he had a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms 3 of 6 residents (Residents #1, #5, and #6) reviewed for physical restraints. The facility failed to ensure Residents #1, #5, and #6 had physician orders for the scoop mattresses on their beds. This failure could prevent the residents from having an environment that was free from physical restraints. Findings include: 1. Record review of Resident #1's Face Sheet, dated 05/14/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included repeated falls, and seizures. Record review of Resident #1's Quarterly MDS assessment, dated 02/11/25, reflected he had a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance. Record review of Resident #1's physician orders,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained as free of accident hazards as was possible for 1 of 6 residents (Resident #4) reviewed for accident prevention. The facility failed to ensure Resident #4 had a fall mat placed alongside her bed while she was lying in it on 05/14/25. This failure could prevent the residents from having an environment that was free and clear of accident hazards. Findings include: Record review of Resident #4's Face Sheet, dated 05/14/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included history of falls, and unsteadiness on feet. Record review of Resident #4's Quarterly MDS assessment, dated 02/06/25, reflected she had a BIMS score of 00 (severe cognitive impairment). For ADL care, it reflected the resident required substantial assistance. Record review of Resident #4's Comprehensive Care Plan, dated 04/08/25, reflected the resident had a hip fracture from a fall and one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure each resident received food that accommodates resident allergies, intolerances, and preferences for 2 residents (Resident #3 and Resident #4) of six residents reviewed for food preferences. -The facility failed to ensure Resident #3 and Resident #4 had nutritious and palatable meal substitutes to meet their intolerances and/or preferences. This failure could place residents at risk of not having their daily nutritional needs met, placing them at risk for weight loss and a diminished quality of life. Findings included : Record review of Resident #3's face sheet, dated 3/26/25, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis affecting left non-dominant side (muscle weakness and partial paralysis), depression (mood disorder), epilepsy (seizure disorder), protein-calorie malnutrition, and GERD. Further…

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 with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 2 residents (Resident #1 and Resident #2) of five residents reviewed for pressure ulcers. 1. The facility failed to document wound care treatments as ordered by the physician in February 2025 to Resident #1's right heel for 7 occurrences and to Resident #1's coccyx (tailbone) for 4 occurrences. 2. The facility failed to document wound care treatments as ordered by the physician in February 2025 to Resident #2's right heel for 7 occurrences and to Resident #2's sacrum (bone at base of spine)/coccyx for 11 occurrences. In [DATE], the facility failed to provide wound care treatments as ordered by the physician to Resident #2's left heel for 2 occurrences, right ankle for 2 occurrences, right heel for 1 occurrence, 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 observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine's left and right-sided vents were free from dust. 2.The facility failed to ensure food items in the refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator and dry storage that were not properly labeled or past the 'best by', discard by or expiration dates. 4. The facility failed to have Dietary staff change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 5. The facility failed to ensure chicken set to thaw in a sink was left to thaw under cold running water. 6. The facility failed to ensure the kitchen was free of pests. 7. The facility failed to ensure all cans stock in area for kitchen use were free from dents 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 use the services of a registered nurse for 8 consecutive hours 7 days a week for all four quarters reviewed for RN coverage. The facility did not have RN coverage for eight consecutive hours on 42 days during the review period. This failure could place residents at risk of lack of nursing oversight and higher level of care needed. Findings included: Record review of the PBJ reports dated Quarter 1 2024 (October 1 - December 31), Quarter 2 2024 (January 1-March 31), Quarter 3 2024 (April 1 - June 30) and Quarter 4 2024 (July 1 - September 30) reflected there were no consecutive 8 hours of RN coverage on 12/16/2023; 12/17/2023; 12/23/2023; 12/24/2023; 12/30/2023; 12/31/2023; 01/06/2024; 01/07/2024; 01/20/2024; 01/21/2024; 01/27/2024; 01/28/2024; 02/03/2024; 02/04/2024; 02/10/2024; 02/11/2024; 02/17/2024; 02/18/2024 04/20/2024; 04/21/2024; 04/27/2024; 04/28/2024; 05/05/2024; 05/11/2024; 05/12/2024; 05/18/2024; 05/19/2024; 05/25/2024; 05/26/2024; 06/08/2024; 06/22/2024; 07/07/2024; 08/03/2024; 08/10/2024; 08/17/2024;…

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 for mobility for 1 of 5 residents reviewed for activities of daily living (Resident #1). The facility did not provide for assistance with activities of daily living by addressing the mobility/transfer needs of Resident #1. The failure could place residents requiring assistance to transfer at risk for developing wounds, infections, generalized deterioration, and loss of functional abilities. Findings included: Review of Resident #1's face sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) for transfers to and from the bed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility in accordance with professional standards and practices, failed to maintain medical records on each resident that are complete and accurately documented, for 1 of 5 residents reviewed for documentation (Resident #1). The facility did not accurately document refusal of transfers by Resident #1. The failure could place residents at risk for not receiving resident-centered plans of care. Findings included: Review of Resident #1's face sheet reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) for transfers to and from the bed to chair/wheelchair. MDS did not indicate pressure-related ulcers. The MDS noted a BIMS score of one, indicating severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure confidential and personal medical records for four (Resident #6, Resident #7, Resident #8, and Resident #9) of four resident reviewed for Privacy and Confidentiality. 1. The facility failed to ensure LVN B would not leave Resident #6's information about her death unattended and visible on top of the nurse's cart on 200 Hall. 2. The facility failed to ensure LVN B would not leave Resident #7's schedule for Norco unattended and visible on top of the nurse's cart on 200 Hall. 3. The facility failed to ensure LVN B would not leave Resident #8's schedule for Baclofen unattended and visible on top of the nurse's cart on 200 Hall. 4. The facility failed to ensure LVN B would not leave Resident #9's vital signs and code status unattended and visible on top of the nurse's cart on 200 Hall. These failures could place the residents at risk of exposure of their personal and medical information to unauthorized individuals. Findings included: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 (room [ROOM NUMBER], #2, #3, #4, and #5) of 5 resident rooms and the handrails reviewed for cleanliness and sanitization. *The facility failed to ensure that Resident Rooms #1, #2, #3, #4, and #5 were thoroughly cleaned and sanitized. *The facility failed to clean and sanitize the handrails, utilized by residents throughout the facility. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 10/30/24 at 10:53 AM of Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black dirt debris and thick dusts. The bathroom floor had thick black dirt along the corners of the floor and around the toilet. The bathroom wall had a large…

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 that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four (Resident #3, Resident #4, Resident #5, and Resident #10) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #3's humidifier had water in it. 2. The facility failed to ensure that Resident #4's breathing mask and nasal cannula (flexible tube used to deliver oxygen to the nose through two prong) were properly stored when not in use. 3. The facility failed to ensure that Resident #5's nasal cannula connected to the portable tank behind the wheelchair was properly stored when not in use. 4. The facility failed to ensure that Resident #10's nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) face mask was properly stored. These…

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

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure the ice machine and the ice scoop, located in the kitchen area, was cleaned. 2. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the stored date. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations of the only kitchen with Dietary Manager A on 10/30/24 from 2:09 PM to 2:15 PM AM reflected the following: *The ice machine, located in the kitchen area, had black stains near the inside door hinges. The inside opening of the ice machine had lights stains. *The ice scoop, hanging in a clear plastic holder, had dirt debris along the bottom of the holder. *One large stainless-steel container of reddish sauce, located in the refrigerator,…

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 the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #1 and Resident #2) of ten residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #1 and Resident #2. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #1 Review of Resident #1's Face Sheet, dated 10/30/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #1's pertinent diagnoses included unsteadiness on feet and muscle weakness. Review of Resident #1's Quarterly MDS Assessment, dated 09/30/2024, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident was 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 interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #4) of 4 residents reviewed for (ADLs) care provided to dependent residents. 1.The facility failed to ensure Resident #4 received scheduled bed baths from October 1, 2024 - October 30, 2024. This failure placed the resident at risk of not receiving necessary services to maintain good personal hygiene, skin breakdown, and decreased self- esteem. Findings included: Record review of Resident #4's Face Sheet, dated 10/31/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive response) and for ADL care it stated, for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement interventions that are consistent with current professional standards of practice for 1 (Resident #11) of 9 residents reviewed for environmental hazards. Resident #11's mattress was raised up on one side using wedges and a pillow. Improper placement of the resident's mattress could put residents at risk for injury or entrapment. The findings included: Review of Resident #11's Face Sheet, dated 10/31/2024, reflected that Resident #11 was a [AGE] year-old female admitted on [DATE]. Resident #11 was diagnosed with acute and chronic respiratory failure with hypoxia (low levels of oxygen), severe intellectual disabilities, autistic disorder (condition that impairs the ability to communicate or interact with others), spastic hemiplegic cerebral palsy (muscle stiffness and lack of muscle control on one side of the body), cognitive communication deficit, and seizures. Review of Resident #11's Quarterly MDS (Minimum Data Set: tool used…

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 store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 (Resident #10) of 9 residents reviewed for medications at the bedside. A box containing vials of nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) medication was left unattended and unsecured on the nightstand at Resident #10's bedside. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Review of Resident #10's Face Sheet, dated 10/31/2024, reflected Resident #10 was an [AGE] year-old male admitted on [DATE]. Resident #10 was diagnosed with COPD (a chronic lung disease, dementia (decline in cognitive abilities), chronic kidney disease, and fracture of the right femur (bone in upper leg).…

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 observations, interviews, 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 one (Resident #3) of eight residents observed for Infection Control. The facility failed to ensure that CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #3. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #3's Face Sheet, dated 10/30/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #3 was diagnosed with gastroenteritis (gastrointestinal infection) and colitis (inflammation of the large intestine). Review of Resident #3's Quarterly MDS Assessment, dated 09/22/2024, reflected the resident was cognitively intact with a BIMS score of 15. Resident #3'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 ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of three residents reviewed for abuse. The Administrator failed to report an incident to the State Survey Agency when Resident #1 alleged PTA A had physically abused him on 10/24/24. This failure could place the residents in the facility at risk of not receiving timely reporting of incidents involving allegations of abuse which could result in undetected abuse and misappropriation or theft and emotional distress. Findings included: Review of Resident #1's face sheet, dated 10/25/24, revealed he originally admitted to the facility on [DATE]. His diagnoses included:…

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 provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for pharmacy services. 1. The facility failed to document that Resident #1 was given albuterol sulfate (for asthma ) on 09/08/2024,and buspirone HCL (for anxiety) on 09/06/2024 2. The facility failed to document that Resident #2 was given atorvastatin calcium (for hyperlipidemia), on 09/12/2024 duloxetine oral (for depression) on 09/12/2024, melatonin (for insomnia) on 09/12/2024, sennosides-docusate sodium (for constipation)on 09/12/2024, and carboxymethyl cellulose (for dry eyes on 09/12/2024,09/13/2024,09/16/2024. This failure could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician. Findings included:…

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to ensure the interdisciplinary team revised and reviewed the plan of care for Resident #1 with interventions following elopement attempts on 07/24/24,08/22/24 and 09/12/24. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Review of Resident #1's electronic face sheet printed 09/18/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Dementia with mood disorder (term used to describe a group of symptoms affecting memory, thinking and social abilities), dementia with psychotic disturbance, anxiety disorder (frequently have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to provide Resident #1 with adequate supervision to prevent her from leaving the building on 07/26/2024, 08/22/2024, and 09/12/2024. This failure placed residents at risk for harm and serious injury. Findings included: Review of Resident #1's electronic face sheet printed 09/18/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to Dementia with mood disorder (term used to describe a group of symptoms affecting memory, thinking and social abilities), dementia with psychotic disturbance, anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations), and insomnia( trouble falling asleep and staying asleep).…

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 immediately inform the resident's representative(s) of a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of three resident reviewed for resident rights. The facility failed to ensure the WCN notified the resident's representative on 01/03/24 that Resident #1 had a change of condition in clinical status (exposed hardware [screw] in the left lower extremity wound). This deficient practice placed residents at high risk or the likelihood of, serious injury, harm, impairment, or death by not having their needs met, or receiving treatment in a timely manner in accordance with professional standards of practice. Findings included: Record review of Resident #1's Face Sheet revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified Fracture of Left Tibia Shaft (The big bone between the knee and ankle. The shaft [shinbone] is the middle…

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 provide a safe, clean, comfortable, and homelike environment for 15 of 23 resident rooms (Resident # #1, 3, 11, 20, 21, 27, 29, 33, 35, 38, 40, 42, 45, 48, and 50) for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms were thoroughly clean and sanitized, and handrails were cleaned and serviced. These failures could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation of Residents # 48 & #50 Room on 11/07/23 at 10:45 AM revealed, the air-condition unit had dirt particles between the vents. The bedside table was heavily stained on the bottom with dirt and fluid stains. The bathroom floor under the sink and around the toilet had light brown stains. The entry way into the bathroom floor had grayish stains across the doorway. Observation of Residents # 35 & #40 Room on 11/07/23 at 10:55 AM…

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 ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #11, #29, and #42) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Residents #11, #29, and #42 received showers consistently based on records reviewed for October 2023 This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #11's Face Sheet, dated 11/08/23, revealed he was a 68 -year-old male initially admitted on [DATE] and readmitted on [DATE]. Relevant diagnoses included Muscle Weakness, Urinary Tract Infection, and Muscle Wasting. Record review of Resident #11's MDS dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 00…

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

Based on interviews and record reviews, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 staff reviewed for activity professional qualifications The facility failed to ensure the activities at the facility was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. These failures could place the residents at risk of not receiving and effective activities program developed and implemented for their physical and mental well-being. Findings included: Record review of the facility's records for proof of Activities Director's credentials indicated the Activity Director was not licensed nor registered as a qualified therapeutic recreation specialist or an activities professional. Interview with the Administrator on 11/09/23 at 03:57 PM, she stated the Activity Director had been at the facility for a couple of months. She stated they trained the Activity Director in Dementia training, and she went to a sister facility and trained with the activity director at 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.

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 for the facility's only kitchen. 1. The facility failed to cover and date food stored in the refrigerator and freezer that should no longer be consumed. 2. The FSM failed to wear hair restraint inside the kitchen area. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: 1. Observation in facility's kitchen on 11/7/2023 at 8:49 AM revealed Sandwiches left in the refrigerator, covered but not dated when it was prepared. 2. Observation in facility's kitchen on 11/7/2023 at 8:51 AM revealed Ground chicken left in the refrigerator, uncovered and undated when it expired. 3. Observation in facility's kitchen on 11/7/2023 at 8:53 AM revealed Chicken patties in the freezer, uncovered, undated when it expired. 4. Observation in facility's kitchen on 11/7/2023 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 ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #53) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #53's rooms was in a position that was accessible to the resident. This failure could place the resident at risk of being unable to obtain assistance and ask fo help in the event of an emergency. Findings included: Review of Resident #53's Face Sheet dated 11/08/2023 reflected that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty in swallowing), muscle wasting and atrophy (decrease in size of a body part), quadriplegia (paralysis that affects all a person's limbs and body…

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 develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 1 of 4 (Residents # 62) Residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 62's use of side rails. This failure could place resident at risk of not having a plan developed to address care needs. Findings include: Review of Resident # 62 face sheet dated 9/6/2023 revealed that Resident was [AGE] year-old male, admitted to the facility on [DATE] with primary medical diagnoses of unspecified severe dementia loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavior disturbances, psychotic disturbance, and anxiety. Review of the Resident #62 MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #29) reviewed for nutrition and hydration. The facility failed to assess Residents #29's weight on a weekly basis per facility's policy regarding 'Nutrition Status Management, and the resident experienced a 7.5% weight loss in a 90-day period. This failure could place resident at risk of experiencing a decline in health due to malnutrition. Findings included: Record review of Resident #29's Face Sheet dated 11/07/23 indicated she was a 73 -year-old female admitted on [DATE]. Relevant diagnoses included Protein - Calorie Malnutrition, and Muscle Weakness. Record review of Resident #29's Minimum Data Set (MDS) on dated 09/28/23 indicated she had a Brief Interview for Mental Status (BIMS) score of 00 (severe cognitive impairment). Record review of Resident #29's Care plan dated 09/25/23…

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 that 2 (Resident #53 and Resident #66) of 4 residents who were fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding. The facility failed to ensure Resident #53's dressing on the g-tube insertion site was changed everyday The facility failed to ensure Resident #66's syringe was changed as per facility' policy. These failures could place the residents at risk for nutritional problems. Findings included: Review of Resident #53's Face Sheet dated 11/08/2023 reflected the that resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty in swallowing), muscle wasting and atrophy (decrease in size of a body part), quadriplegia (paralysis that affects all a person's limbs and body from the neck down),…

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 was provided such care, consistent with professional standards of practice for 2 of 3 Residents (#270 and 51) reviewed for respiratory care, in that: Resident #270 did not have physician orders for oxygen administration and humidity bottle was not label or dated. Resident #51's oxygen concentrator humidifier was labeled but was not dated and failed to include the mode of administration in the order for Resident #51's oxygen administration. The findings were: Review of Resident # 270's face sheet dated 9/4/2023 reflected that Resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses include Chronic Obstructive pulmonary disease with exacerbation, Acute and chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body), acute and respiratory failure with hypercapnia (high levels of carbon dioxide in body), sleep apnea (a potentially serious sleep…

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 assess and obtain consent for bed for one of one resident (Resident #62) reviewed for bed rails in that: 1. Resident #62 was not assessed, did not have a consent, and did not have an order on the electronic medical record for the use of bedrails or side bars. 2. Resident #62 did not have any care plan documentation for the use of bed rails or side bars This deficient practice could affect Residents who utilized some type of bedrail in the facility and could put the Residents at risk for potential injuries. The findings were: Review of Resident # 62 face sheet dated 9/6/2023 revealed that Resident was [AGE] year-old male, admitted to the facility on [DATE] with primary medical diagnoses of unspecified severe dementia (loss of memory), language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavior disturbances, psychotic disturbance, and anxiety. Review of the Resident # 62 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, interviews and record reviews the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in §483.70(g) for 1 of 6 residents (Resident #48) reviewed for pharmacy services. The facility failed to ensure Resident #48 had received his insulin medications as scheduled and as ordered by his physician. This failure could place residents at risk of health complications. Findings included: Record review of Resident #48's Face Sheet, dated 11/08/23, revealed he was an 67 -year-old male originally admitted on [DATE] and readmitted on [DATE]. Relevant diagnoses included Type 2 Diabetes, and Cataract (cloudy eyes). Record review of Resident #48's MDS dated [DATE] revealed he had a BIMS score of 15 (cognitively intact). Review of Resident #48's Physician Orders dated 11/09/23 revealed orders for the following effective 10/16/2023: Insulin Glargine - Subcutaneous Solution Pen- Injector 100 Unit/ML inject 12 unit subcutaneously at bedtime 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 observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #56) of 10 residents observed for infection control. The facility failed to ensure Resident #56's nebulizer (a medical equipment that can help deliver medication directly to the lungs) mask was not on top of the table when not in use. This failure could place the resident at risk of cross-contamination and development of infection. Findings included: Review of Resident #56's Face Sheet dated 11/08/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease ( a chronic inflammatory lung disease that causes obstructed airflow from the lungs), cognitive communication deficit, unspecified noninfective gastroenteritis (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 provide food that accommodated resident allergies, intolerances, and preferences for one (Resident #205) of 5 residents reviewed for food preferences. The facility failed to honor Resident #1's dislike of pork products and gravy, and served him ham with gravy. This failure could place residents at risk for malnutrition and poor quality of life. Findings included: Review of Resident #1's quarterly MDS assessment, dated 08/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], from the hospital. He was able to understand others and be understood, had long and short term memory problems, and moderately impaired decision making skills regarding day-to-day decisions. He rejected care daily during the assessment period, but exhibited no other behaviors or psychosis. Resident #1 had diagnoses of stroke, dysphagia (problems with swallowing), and schizophrenia, and required supervision at meals, but did not exhibit signs…

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 store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one (Resident #1) of four residents observed for pharmacy services. MA B failed to ensure Resident #1's medications were not left at his bedside. These failures could affect residents by placing them at risk of increased medication diversion. Findings included: Review of Resident #1's face sheet dated 08/22/23 revealed a [AGE] year-old male admitted to the facility on 07/25/ 23 with diagnoses of severed protein-calorie malnutrition, hyperlipidemia, hypertension, and osteoporosis. Review of Resident #1's admission MDS dated [DATE] reflected he had a BIMS score of 10 which suggested a moderately impaired mental status. Review of Resident #1's Medication Administration Record dated 08/22/23 revealed his Omega-3 Fatty Acids Capsule 1000 mg, 1 tablet to be given by mouth three times a day 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.

Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances brought up by Resident Council for 2 (June 2023 and July 2023) of 2 Resident Council meetings reviewed for grievances. The facility did not ensure the Administrator attended Resident Council Meeting after being invited for 2 months in a row (June 2023 and July 2023). These failures could place residents at risk for grievances not being addressed or resolved promptly leading to residents feeling like they are not being heard. Findings included: Review of Resident Council Minutes provided by Administrator for 6/14/23 indicated the Administrator was invited but was absent. Review of Resident Council Minutes provided by Activities Director for 6/14/23 revealed, Residents stated they like Administrator to attend the Residents meeting so they can voice out their issues with the Administrator. Review of Resident Council Minutes provided by Administrator for 7/12/23 indicated the Administrator was invited but did not attend. Further review of the minutes indicated Issues last…

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.