Kemp Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 24 residents (Resident #20) reviewed for medications at their bedside. The facility did not ensure Resident #20's Ayr Nasal Solution (nasal spray), and biotene dry mouth moisturizing spray were not left on his bedside table. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.Findings included: Record review of Resident #20's face sheet, dated 07/01/25, reflected Resident #20 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included diastolic (congestive) heart failure (occurs when the heart's lower left chamber becomes stiff and cannot relax and fill with blood properly between beats). Record review of Resident #20's quarterly MDS, dated [DATE], reflected Resident #20…

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 all residents were provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs for 1 of 2 residents (Resident #19) reviewed for dietary needs and preferences. The facility failed to ensure Resident #19 received small, frequent meals as recommended by her physician. This failure placed residents at risk for altered nutritional status and decreased quality of life. Findings included: Record review of Resident #19's face sheet dated 07/02/2025 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus with other circulatory complications (insulin resistance leading to high blood sugars resulting in complications with circulation), gastro-esophageal reflux disease without esophagitis (a long-term condition in which acid from the stomach comes up into the esophagus without inflammation of the…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure:1. The ham was discarded after the use by date of 06/26/25.2. The potatoes were labeled and dated. These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation of the kitchen on 06/29/25 beginning at 11:20 AM, the following was revealed in the fridge: Ham had a use by date of 06/26/25. Potatoes were found in a container with no label or date. During an interview on 07/01/25 at 2:54 PM, the Dietary Manager said the ham was unfortunately 1 day out of date. She said the potatoes had just been pulled from the freezer, were labeled, and dated but the label had gotten soggy from the ice. She said a new label should have been placed. The Dietary Manager said the ham should have been pulled on the day it expired and thrown away. She said the fridges were checked daily for expired food and she 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 observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #44) reviewed for infection control. The facility failed to ensure CNA N performed hand hygiene while providing incontinent care for Resident #44 on 06/29/25. This failure could place any resident at the facility at risk for cross-contamination and the spread of infection.Finding included: Record review of Resident #44's face sheet, dated 07/02/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Neuromuscular dysfunction of the bladder (occurs when the nerves controlling the bladder are damaged or don't function properly, leading to issues with storage and/or emptying of urine), stroke and diabetes (high…

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 implement written policies that prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation for 1 of 69 (Resident #1) residents reviewed for abuse and neglect. The facility failed to implement the abuse and neglect policy and procedure regarding reporting misappropriation of property for Resident #1. This failure could place the residents at increased risk for abuse and neglect. The findings included: Record Review of the abuse and neglect policy dated 3/29/18 indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation. Or punishment resulting physical harm. pain or mental anguish. Abuse also includes the deprivation by an individual. including a caretaker, of goods or services that are necessary to attain or maintain physical. mental. and psychosocial well-being. Instances of abuse of all residents. irrespective of any mental or physical condition. cause physical harm, pain or mental…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is 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, 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 1 of 69 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 24 hours of being notified of misappropriation of property for Resident #1. This failure to report could…

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 in response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, or mistreatment while the investigation was in progress. And report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1of 69 (Resident #1) residents reviewed for Abuse and Neglect. The facility's Administrator failed to ensure on Resident #1's misappropriation of property was thoroughly investigated. This failure could place residents at risk for ANE. Findings included: Record Review of the abuse and neglect policy dated 3/29/18 indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation. Or punishment resulting physical harm. pain or mental anguish. Abuse also…

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 sufficient staff to provide nursing related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, for 2 of 22 residents (Resident #54 and Resident #219) and 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient staff to provide prompt and proper incontinent care for Resident #54 and Resident #219. This failure could place residents at risk of an unsafe environment, new pressure injuries, worsening of pressure injuries, falls, and exacerbations of disease processes. Findings Included: 1. Record Review of Time Sheets between 04/14/2024-05/02/2024 indicated number of CNAs worked: 04/14/20224: 1 CNA from 1:31pm- 9:56pm; 1 CNA from 6:19am-6:02 pm, 1 CNA from 6 pm-6:18am. 04/15/2024:1 CNA from 5:55 am-6:09 pm, 1 CNA from 1:39 pm-9:54 pm, 1 CNA from 5:52 am-6:16 pm, 1 CNA from 3:31 am -11:33am, 1 CNA from 7:35…

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 9.During an observation on 04/29/2024 at 10:52 p.m., PVC plastic clean linen cart sitting in the hallway with cover was open. During an interview on 04/29/2024 at 11:03 p.m., NA Q stated the PVC plastic linen cart cover should always be closed. NA Q stated it was his responsibility to make sure he closed the cover. NA Q stated it was important to keep the cover closed so microorganisms in the hallway would not get on the liens. NA Q stated the failure would be the supplies and linens getting contaminated and cause infection. During an interview on 04/29/2024 at 11:20 p.m., LVN T stated the linen cart cover should be closed. LVN T stated it was the CNAs responsibility to close the cover when they were done. LVN T stated she would do an in-service. LVN T stated the charge nurse was responsible for making sure the CNAs did their jobs. LVN T stated it was important to keep the cover closed for infection control. LVN T stated the failure was the linens could become soiled and the resident could get an infection.…

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

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response for 8 of 8 confidential residents reviewed for resident council. The facility failed to ensure there was documentation of the facility's efforts to resolve concerns collected at the resident council meetings on 10/10/23, 11/14/23, 12/12/23, 01/09/24, 02/13/24, and 03/12/24. This failure could place residents at risk of not having their concerns and grievances followed through and a diminished quality of life. Findings included: Record review of the Resident Advisory Council Minutes for 10/10/23 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 11/14/23 indicated the call lights were not being answered timely. Record review of the Resident Advisory Council Minutes for 12/12/23 indicated the call lights were not being…

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 2. Record review of Resident #31's face sheet dated 05/02/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses heart disease, congestive heart failure, kidney disease, high blood pressure and depression. Record review of Resident #31's quarterly MDs assessment dated [DATE] indicated he had a BIMS score of 08 which indicated he had moderately impaired cognition. The MDS also indicate he required limited assistance for bed mobility, extensive assistance for toileting, bathing, and transfers, and setup for eating. Record review of Resident #31's undated care plan indicated he required supervision of 1 staff for bathing. Record review of Resident #31's documentation survey report for baths dated April 2024 indicated he was scheduled for baths on Monday Wednesday and Fridays on the 2PM-10PM shift and received 2 out of the 13 scheduled baths for the month of April. During an interview on 04/28/24 at 03:54 PM Resident #31 said he does not get his…

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 accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 5 of 6 residents (Resident #12, Resident #26, Resident #39, Resident #165, and Resident #218) reviewed for pharmacy services. 1. The facility failed to ensure Resident #26's buspirone (anxiety medication), gabapentin (medication for nerve pain), duloxetine (medication for depression), and metoprolol succinate (blood pressure medication) were administered timely. 2. The facility failed to ensure Resident #218's spironolactone (medication used to treat fluid buildup), metoprolol (blood pressure medication), venlafaxine hydrochloride (medication for depression), and pregabalin (used to treat nerve pain) were administered timely. 3. The facility failed to administer the following medications as prescribed for Resident #165: Aspirin (medication works by stopping platelets from clumping together) Omeprazole…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 5 medication carts (Hall 200 medication cart, Treatment medication cart) and 1 of 22 residents (Resident #36) reviewed for pharmacy services. 1. The facility failed to ensure Resident #36 did not have prescribed and OTC medications at bedside. 2. The facility failed to ensure the treatment nurse ensured the medication cart, used for treatments, was locked when it was left unattended. 3. The facility failed to ensure LVN M ensured the 200 Hall medication cart was locked when it was left unattended. These failures could place residents at risk of injury from medication misuse or drug diversion. 1.Record review of Resident #36's face sheet dated 05/02/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 6 resident rooms (room [ROOM NUMBER]) reviewed for the homelike environment. The facility failed to ensure Resident #4's room was without urine odor during the surveyors observation 04/28/24 through 05/02/24. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept and clean environment. Findings included: 1.Record review of Resident #4's face sheet dated 05/02/24, indicated a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including seizures, Pseudobulbar affect {PBA} (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), high blood pressure, and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Record review of Resident #4's quarterly MDS assessment 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 the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 22 residents (Resident #219) reviewed for abuse and neglect. The facility failed to ensure CNA G and SNA H provided incontinent care every two hours as required for Resident #219 on 04/30/24, which resulted in a strong urine odor and wet, brown stains to her sheets and mattress. This failure could result in pressure injuries, infections, psychosocial harm, and a decreased quality of life. Findings included: Record review of a face sheet dated 05/02/24 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and vascular dementia without behavioral disturbance,…

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 implement their written policies and procedures to prohibit neglect and abuse for 1 of 22 residents (Resident #11 and Resident #219) reviewed for abuse and 1 of 21 staff (LVN K) reviewed for abuse training. The facility failed to ensure the Social Worker followed the facility's policy when he did not immediately report Resident #11's allegation of verbal abuse by Resident #219 to the Administrator on 04/28/24. The facility failed to follow its policy when LVN K did not complete abuse training upon hire on 03/05/24. These failures could place residents at risk of abuse, neglect, and decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #11 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and anxiety disorder (mental illness…

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 22 residents (Resident #11 and Resident #219) reviewed for abuse and neglect reporting. The facility failed to ensure the Social Worker reported Resident #11's allegation of verbal abuse by Resident #219 immediately to the Administrator on 04/28/24. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #11 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and anxiety disorder (mental illness defined by feelings of uneasiness,…

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 develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 4 (Resident #54) residents reviewed for comprehensive person-centered care plans. The facility failed to care plan Resident #54's interventions, diagnoses, and medication use of Trazodone (an antidepressant medication used to help with her sleep). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1.Record review of Resident #54's face sheet, dated 05/02/24, indicated Resident #54 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included insomnia, high blood pressure, Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday…

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 was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 22 residents (Resident #219) reviewed for incontinence. 1. The facility failed to ensure Resident #219 was provided prompt and proper incontinent care. 2. The facility failed to ensure CNA C properly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #54. These failures could place residents at risk for urinary tract infections, skin breakdown, and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #219 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes…

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 respiratory care was provided consistent with professional standards of practice for 2 of 4 residents (Residents #19 and Resident #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #19's handheld nebulizer was properly stored. 2. The facility failed to properly store Resident #8's nasal cannula. 3. The facility failed to properly clean Resident #8's oxygen concentrator. These failures could place residents requiring respiratory care at risk for respiratory infections or complications. Findings included: 1. Record review of a face sheet dated 05/02/24 indicated Resident #19 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #19 was able…

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 review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 (Resident #46) of 5 Residents, reviewed for pharmacy services. The facility failed to ensure that Resident #46 did not receive an antipsychotic (Seroquel/Quetiapine Fumarate) that was not necessary to treat Vascular Dementia. This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #46's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses of Vascular Dementia (a series of strokes that caused decreased oxygen to the brain and neurological deficits), anxiety disorder (unpleasant state of inner turmoil), chronic obstructive pulmonary disease (progressive lung disease characterized by long term respiratory…

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 it was free of medication error rates of 5 percent or greater. The facility had a medication error rate of 10.0%, based on 4 errors out of 40 opportunities, which involved 2of 6 residents (Resident #165 and Resident #12) reviewed for medication administration. 1. The facility failed to ensure RN A administered the correct dose of Aspirin 81 MG and Omeprazole 40 MG, (Aspirin and omeprazole combination is used in patients who need aspirin to prevent heart and blood vessel problems (e.g., heart attack, stroke). RN A failed to administer Lyrica 75MG (used to treat pain caused by nerve damage due to diabetes) on 04/29/24 as ordered. 2. The facility failed to ensure RN A administered the correct dose of Aspirin 81MG (a type of NSAID that can treat mild to moderate pain and inflammation. It also lowers your risk of heart attack, stroke, or blood clot) on 04/29/24. This failure could place residents at risk of not receiving the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 (Resident #2) residents reviewed for quality of care. 1.The facility failed to ensure Resident #2's venous stasis ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) treatment was performed daily as ordered. 2.The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #2 . These failures could result in residents with venous stasis ulcer of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings included: 1. Record review of the face sheet dated 3/6/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the right…

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 necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 5 (Resident #1) residents reviewed for pressure injuries. The facility failed to ensure Resident #1's wound care was performed daily as ordered . These failures could place residents at risk for worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: 1. Record review of the face sheet dated 3/5/24 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including dementia, diabetes, COPD, hydronephrosis, and chronic pain. Record review of the physician orders dated 3/5/24 indicated Resident #1 had an order to cleanse coccyx (small triangular bone at the base of the spinal column) with normal saline, pat dry, apply collagen (used to treat partial-thickness wounds…

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 a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 1 (Resident #1) residents reviewed for incontinence care. The facility failed to ensure Resident #1's discharge order for a urinary straight catheter (also called an intermittent catheter, is a soft, thin tube used to pass urine from the body) four times a day was initiated upon re-admission to the facility . This failure could place residents at risk for urinary retention (difficulty urinating and completely emptying the bladder), pain, and urinary tract infections. Findings included: 1. Record review of the face sheet dated 3/5/24 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including dementia, diabetes, COPD, hydronephrosis, and chronic pain. Record review of the physician orders dated 3/5/24 indicated Resident #1 did not have an order for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records.for 2 of 5 (Resident #2 and Resident #3) residents reviewed for resident rights. 1. The facility did not ensure the door was closed during wound care on Resident #2 resulting in another resident trying to enter the room to speak with the nurse during Resident #2's wound care . 2. The facility failed to prevent RN A from discussing Resident #3 with Resident #2. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of the face sheet dated 3/6/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the right and left lower limb, lymphedema (swelling, most often in the arm or leg, caused by a lymphatic system (a network 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 provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 9 (Resident #1) residents reviewed for pharmacy services. The facility failed to only administer medication prescribed by the physician to Resident #1. The noncompliance was identified as PNC. The noncompliance began on 9/05/23 and ended on 9/07/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for adverse reactions. Findings Include: Record review of the face sheet dated 9/15/23 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, cerebral infarction (stroke), myocardial infarction (heart attack), hypertension (high blood pressure), chronic kidney disease, and cognitive communication deficit. Record review of the MDS assessment dated [DATE] indicated 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.