Lake Village Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to incorporate the recommendations from the PASARR evaluation report into the resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 3 residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for nursing facility specialized services in the long-term care online portal within 20 business days after the annual interdisciplinary team meeting on 03/04/2025. Resident #1 did not receive a repositioning wedge as recommended on the PASRR Comprehensive Service Plan. This failure could place residents at risk of not receiving individualized care and specialized services to meet their needs. The findings include: Record review of Resident #1's Face Sheet, dated 09/16/2025, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included frontal lobe executive function deficit (impacts the ability to manage thoughts, emotions, and behavior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of five residents observed for infection control. The facility failed to ensure that LVN B washed her hands or used hand sanitizer while administering medication to Resident #2 on 09/16/2025. This failure could place the residents at risk of cross-contamination and the development of infections.Findings include:Review of Resident #2's Face Sheet, dated 09/16/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses which included hypertension (elevated blood pressure) and cellulitis (skin infection) of the right lower limb. Review of Resident #2's Quarterly MDS Assessment, dated 08/30/2025, reflected moderately impaired cognition with a BIMS score of 08. Section I…

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 six (Residents #35, #36, #49, #168, #169, and #171) of twenty residents reviewed for Infection Control. 1. The facility failed to ensure CNA D and CNA E changed their gloves and performed hand hygiene while providing incontinent care to Resident #35 on 03/04/2025. 2. The facility failed to ensure LVN J sanitized the blood pressure cuff and the pulse oximeter while administering medications and checking the vital signs of Residents #36, #49, #168, #169, and #171 on 03/05/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #35's Face Sheet, dated 03/04/2025, reflected an [AGE] year-old female who was admitted to 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 observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #45) of twenty residents reviewed for Dignity. The facility failed to ensure CNA F did not stand behind Resident #45 while assisting the resident to eat during lunchtime on 03/04/2025. This failure placed residents at risk of not having their right to a dignified existence maintained. Findings included: Review of Resident #45's Face Sheet, dated 03/05/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with lack of coordination and muscle weakness. Review of Resident #45's Quarterly MDS Assessment, dated 02/27/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required moderate assistance (refers to providing…

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 one (Residents #8) of twenty residents reviewed for Privacy and Confidentiality. The facility failed to ensure LVN G closed, locked, or minimized her laptop's monitor while administering medication to Resident #8 on 03/04/2025. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals. Findings included: Review of Resident #8's Face Sheet, dated 03/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with anxiety disorder (intense or excessive fear or worry). Review of Resident #8's Quarterly MDS Assessment, dated 12/23/2024, revealed the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had anxiety disorder. Review of Resident #8's Comprehensive Care Plan, dated 01/08/2025, 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #62) of eight residents reviewed for Care Plans. The facility failed to ensure Resident #62's care plan, dated 02/23/2025, included her CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) usage. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #62's Face Sheet, dated 03/04/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #62) of twelve residents reviewed for Respiratory Care. The facility failed to ensure Resident #62 had an order for her CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) on 03/04/2025. This failure could place residents at risk for not having their respiratory needs met. Findings included: Record review of Resident #62's Face Sheet, dated 03/04/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #62's Quarterly MDS Assessment, dated 02/27/2025, reflected the resident was unable 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 observation, interview, 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 for one (Resident #36) of five residents reviewed for Pharmaceutical Services. The facility failed to ensure LVN J disposed of Resident #36's Tramadol properly on 03/05/2025. This failure could place residents at risk of not receiving medications as ordered by the physician. Findings included: Record review of Resident #36's Face Sheet, dated 03/05/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with polyneuropathy (a condition that damages many nerves in the body) and osteoarthritis (inflammation of one or more joints). Record review of Resident #36's Quarterly MDS Assessment, dated 02/04/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident had…

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 ensure that drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one cart (nurse's cart) of seven carts observed. The facility failed to ensure that LVN G locked her nurse's cart while passing medication at hall 300 on 03/04/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications. Findings included: Observation on 03/04/2025 at 9:32 AM revealed a nurse's cart was in the middle of hall 300 hallway. The nurse's cart was left unlocked. The drawers of the cart contained various blister packs of medication, eyedrops, insulin, and insulin paraphernalia. Several staff passed by the nurse's cart and did not notice the cart was unlocked. Observation and interview with ADON A on 03/04/2025 at 9:38 AM revealed ADON A saw the nurse's cart was not locked. She pushed the cart's lock and said the cart should not be left unlocked. She said the staff should lock the cart 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 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 2 (Rooms 303b, 307 b) of 6 resident rooms and all hallway handrails in the facility reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms # 303b, and 307 b were thoroughly cleaned and sanitized. The facility failed to ensure that the facility hallway handrails were cleaned. 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 12/04/24 at 10:40 AM of all the facility hallway handrails revealed dark and light dirt along the brown wooden rails. An observation on 12/04/24 at 12:00 PM of room [ROOM NUMBER] b reflected the top of the 5-drawer chest had a large circular white patch of powdery substance. Interview on…

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

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. The facility failed to ensure the ice scoop, ice scoop holder, and ice machine in the facility's dining area was cleaned. This failure could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 12/04/24 at 10:35 AM in the facility's only dining area reflected: The ice scoop was placed in a clear plastic bag and then placed in a hanging blue plastic holder. The plastic bag had water at the bottom of the bag. The white ice scoop had black marks on the inside and outside of it. The light bluish inside front opening of the ice machine had light brownish stains going horizontally along the machine. In an interview on 12/04/24 at 10:45 AM, the Dietary Supervisor stated that they cleaned the ice machine at least three times a month…

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 interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, reviewed for RN coverage. The facility failed to ensure the facility maintained the required RN coverage for 14 days between August - September 2023. This failure placed residents at risk of receiving higher levels of patient care. Findings included: Review of the facility provided time sheets for Registered Nurses (RN) for the review period from August 2023 - January 2024, revealed the facility failed to have the required RN coverage of at least 8 consecutive hours a day, for the following dates: 08/05/23: 4 hours recorded 08/06/23: 4 hours recorded 08/12/23: 4 hours recorded 08/13/23: 4 hours recorded 08/19/23: 4 hours recorded 08/20/23: 4 hours recorded 08/26/23: 4 hours recorded 08/27/23: 4 hours recorded 09/02/23: 4 hours recorded 09/03/23: 4 hours recorded 09/09/23: 4 hours recorded 09/10/23: 4 hours recorded 09/23/23: 4 hours recorded 09/24/23: 4 hours recorded In an interview on 01/26/24 at 01:50 PM with the DON,…

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 three (Resident #228, Resident #7, and Resident #39) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #228, #7, and #39's rooms were in a position that was accessible to the residents. 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 #228 Review of Resident #228's Face Sheet dated 01/24/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included fracture of the humerus (long bone in the arm that runs from the shoulder to the elbow) of the right arm and falls. Review of Resident #228's Quarterly MDS assessment dated [DATE] reflected resident had a moderated impairment 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.

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 areas in the facility for 6 (Resident #5, #19, #30, #33, 43, and #51) of 20 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #5, #19, #30, #33, 43, and #51's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: Observation of Resident #30's room on 01/24/24 at 10:49 AM reflected the bedside table had white fluid stains along the bottom rail. The bathroom floor had brownish stains near the toilet and the corners of the wall. Observation of Resident #19 and 33's room on 01/24/24 at 10:53 AM reflected the floor along the walls had built up black dirt stains. The wall behind the entry door had dark brown stains. Observation 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 interviews, and record review 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 of 3 residents (Resident #51) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #51 received showers consistently. 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: Resident #51 Record review of Resident #51's face sheet dated 01/26/24 reflected an [AGE] year-old male who was originally admitted to the facility on [DATE]. Relevant diagnosis included need for assistance for personal care, history of falls, and right artificial hip. Record review of Resident #51's Quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 05 (severe cognitive impairment). The resident required assist…

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. The facility failed to ensure food in the facility's refrigerator, was labeled and dated. The facility failed to ensure food in the freezer was not exposed from air-borne contaminants. The facility failed to ensure the ice machine, located in the facility's kitchen, was thoroughly cleaned. The facility failed to ensure the trash can in the kitchen area was covered. The facility failed to ensure the tea dispenser was covered after being prepared. The facility failed to ensure the ice chest located in the dining area was clean and sanitized. The facility failed to ensure the Dietary Manager wore a head covering, while in the kitchen preparing food. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 #228) of 5 residents reviewed for dignity. The facility failed to treat Resident #288 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for his catheter bag. 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: Review of Resident #228's Face Sheet dated 01/24/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included acute kidney failure and neuromuscular (combination of the nervous system and muscles) dysfunction of the bladder. Review of Resident #228's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 8 (Resident #13) residents reviewed for restraints. The facility failed to ensure they had physician orders for the scoop mattress being used for Resident #13. These failures could unnecessarily inhibit the residents' freedom of movement or activity. Findings included: 1. Record review of Resident #13's MDS assessment, dated 10/16/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was severely impaired. Her diagnoses included right hip fracture and multiple falls. Record review of Resident #13's January 2024, Physician Orders reflected there were no orders for a scoop mattress. (a mattress with elevated sides used to limit the ability to get out of bed). Record review of Resident #13'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, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (Resident #288 and Resident #7) of six residents reviewed for Care Plans. The facility failed to ensure Resident #288 was care planned for catheter care. The facility failed to ensure Resident #7 had interventions on her care plan for fall. These failures could place the residents at risk of needs not being met. Findings included: Resident # 228 Review of Resident #228's Face Sheet dated 01/24/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included acute kidney failure and neuromuscular (combination of the nervous system and muscles) dysfunction 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to provide an environment that was free from accident and hazards to prevent accidents for 1 (Resident #54) of 6 residents reviewed for accidents free of hazards. The facility failed to ensure Resident #54's fall mat was placed alongside her bed while she was laying in the bed. This failure placed the residents at risk of accidents and hazards. Findings Included: Record review of Resident #54's Face Sheet, dated 01/24/23, reflected she was an 82 -year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting and atrophy (decrease in muscle tissue), and repeated falls. Record review of Resident #54's Quarterly MDS dated [DATE] reflected the resident's BIMS was 00 (Severe Cognitive Impairment). The MDS indicated the resident had an active diagnosis for syncope (fainting) and collapse. Record Review of the Resident #54's Comprehensive Care Plan updated 01/18/24 reflected the resident was care planned for repeated falls, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #58 and Resident #10) of three residents reviewed for respiratory care. The facility failed to ensure Resident #58 and Resident #10's nasal cannula was properly stored when not in use. The facility failed to ensure Resident #58 and Resident #10's humidifier bottles had water in it. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #58 Review of Resident #58's Face Sheet dated 01/24/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included respiratory failure with hypoxia (insufficient amount of oxygen in the body), pneumonia (inflammation and fluid in the lungs caused by 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 interviews and record reviews the facility failed to ensure medical records were accurately documented for 1 of 3 residents (Resident #2) reviewed for notification of changes. The facility inaccurately documented that the family of Resident #2 was notified following a fall. This failure could place the residents at risk for not having accurate records. Findings include: Record review of Resident #2's face sheet dated 01/26/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnosis included repeated falls, and muscle wasting and atrophy (decrease in muscle tissue). Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 10 (cognitively intact). The assessment also indicated the resident had an active diagnosis for repeated falls. Record review of Resident #2's Comprehensive Care Plan dated 12/05/23 reflected the resident was care planned for repeated falls, with the last fall occurring on 01/18/24, and 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.