Focused Care at Linden

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 7 reviewed for abuse. (Resident #1) The facility failed to ensure Resident #1 was free from abuse when RCP A told Resident #1, You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C. This failure could place residents at risk for verbal abuse and emotional harm.Findings included:Record review of a face sheet dated 07/14/25 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and anxiety disorder. Record review of an annual MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognition. The 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 interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 7 residents reviewed for abuse and neglect.The facility failed to prevent Resident #1 from being abused when RCP A told Resident #1 You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C.The facility failed to immediately suspend RCP A. The facility staff failed to immediately interview Resident #1 concerning the allegations. These failures could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included:Record review of a face sheet dated 07/14/25 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs), bipolar…

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 all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 6 residents reviewed for abuse and neglect. (Resident #1) The facility staff (RCP A, LVN B, and the Social Worker) failed to report an allegation of abuse immediately to the Abuse Coordinator after Resident #1 alleged that RCP D threw a blanket on her face and told her to shut the hell up. This failure could place residents at risk for abuse and neglect. Findings included: Record review of a face sheet dated 04/09/25 revealed Resident #1 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type (combines symptoms of both schizophrenia (like hallucinations and delusions) and bipolar disorder (like mania and depression), diabetes, and high blood pressure. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood 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 interviews and record review the facility failed to complete a performance review of each Resident Care Provider (RCP) at least once every 12 months, for 5 of 5 (RCP L, RCP O, RCP U, RCP V, and RCP W) reviewed for annual competency evaluations. The facility failed to complete annual RCP (facility titles CNA as RCP) competency evaluations for RCP L, RCP O, RCP U, RCP V, and RCP W based on the personnel file review results. This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of the Personnel File Review completed on 02/12/25, indicated RCP L, RCP O, RCP U, RCP V, and RCP W did not have a competency evaluation on file. The Personnel File Review indicated RCP L's date of hire was 01/07/25, RCP O 12/5/24, RCP U 12/5/24, RCP V 10/17/24, and RCP W 11/21/24. During an interview on 02/12/25 at 1:44 p.m., the Director of Nurses said that she did not know if the RCP (CNA) competencies had been completed. She said she could not find them. She said 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 of 13 residents reviewed for care plans (Resident #1, Resident #11, and Resident #15). The facility failed to ensure Resident #1's history of a fall, with a fracture prior to admission, triggered on the 12/08/24 MDS and actual fall on 01/15/25 were care planned. The facility failed to ensure Resident #1's unplanned weight loss experienced on 01/07/25, was care planned. The facility failed to ensure Resident #1's risk of pressure ulcers (is a localized area of skin damage that develops when pressure on the skin cuts off blood flow to the area), triggered on the 12/08/24 MDS, was care planned. The facility failed to ensure Resident #1 experienced pain and received pain…

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 respiratory care was provided consistent with professional standards of practice for 4 of 18 residents reviewed for respiratory care. (Resident #18, Resident #22, Resident #24, and Resident #38) 1. The facility failed to ensure Resident #18 had a filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient was of high quality) in the oxygen concentrator (takes air from the surroundings, extracts oxygen, and filters it into purified oxygen for resident to breathe). 2. The facility failed to ensure Resident #18's compartment that would have held the oxygen concentrator filter did not have gray fuzzy and hair-like particles covering the air intake area. 3. The facility failed to ensure Resident #24's oxygen concentrator filter was not covered in thick gray fuzzy and hair-like particles. 4. The facility failed to ensure Resident #22's oxygen concentrator filter 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 interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 13 residents (Resident #1 and Resident #15) reviewed for pharmacy services. The facility failed to ensure Resident #1's Atorvastatin (is medication used to lower cholesterol and triglycerides (fats) levels to help prevent heart disease, angina (chest pain), strokes, and heart attacks) was available for administration on 01/28/25. The facility failed to ensure Resident #1's Cannabidiol (is an active cannabinoid used as an adjunctive treatment for the management of seizures) was available for administration on 01/10/25, 01/13/25, 01/14/25, 01/15/25, and 01/16/25. The facility failed to ensure Resident #1's Lamotrigine (is a medication used to treat epilepsy and stabilize mood in bipolar disorder) was available for administration on 01/15/25, 01/16/25, 01/17/25, 01/18/25, and 01/19/25. The facility failed 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 interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 3 of 18 residents reviewed for the right to be informed. (Resident's #1, Resident #17, and Resident #18) 1. The facility failed to ensure Resident #1's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consent was completed upon admission and prior to the administration for Sertraline (is an antidepressant). Resident #1's Sertraline was prescribed on 12/03/24. 2. The facility failed to ensure Resident #17's Consent for Antipsychotic (used to treat certain mental/mood disorders) or Neuroleptic (also known as Antipsychotic) Medication Treatment HHSC Form 3713 was correctly completed for Seroquel (Quetiapine) (antipsychotic medication 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 observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 18 (Resident #18) residents reviewed for call lights. The facility failed to ensure Resident #18's call light button was within reach while Resident #18 was in her bed as evidenced by call light button was draped over the nightstand against the wall on her left side. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #18's face sheet dated 2/10/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #18 had diagnoses which included Severe Morbid Obesity (severely overweight), reduced mobility, history of Cerebrovascular Disease (disruption of blood supply to the brain), hemiplegia and hemiparesis following Cerebral Infarction affecting 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 interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 5 residents (Resident #7) reviewed for PASRR. The facility failed to refer Resident #7 for a PASRR review following a new mental illness diagnosis of Bipolar Disorder (mental illness associated with episodes of mood swings ranging from extreme sadness to excitement) on 05/23/23. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #7's face sheet dated 2/10/25 indicated she was [AGE] years old and admitted initially to the facility on [DATE]. Resident #7 had diagnoses which included Bipolar Disorder with on onset date of 5/23/23. Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7 made herself understood 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 interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #9) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #9. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (Major Depressive Disorder, Schizoaffective Disorder, Bipolar Disorder) were present upon Resident #9's admission date on 12/30/22. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #9's face sheet, dated 11/18/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE], and readmitted most recently on 04/20/23. His diagnoses included Major Depressive Disorder (a mood…

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 baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 6 residents reviewed for new admissions (Resident #93). The facility failed to provide Resident #93, a copy of the summary of the baseline care plan. Resident #93 was admitted on [DATE] and had not received a copy of the summary as of 02/10/25. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 13 residents (Resident #93) reviewed for ADL (activities of daily living) care. The facility failed to ensure Resident #93 was provided oral care on 02/10/25. The facility failed to ensure Resident #93 was provided bed baths on 02/10/25. Theses failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, decrease socialization and skin breakdown. Findings included: Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood),…

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 adequate supervision to prevent accidents for 2 of 16 residents (Resident #12, Resident #35) reviewed for adequate supervision. The facility failed to prevent Resident #35 from having rubbing alcohol in his room. The facility failed to ensure that electrical wires were encased in their protective covering and not exposed for Resident #12 These failures could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of Resident #35's admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Acute and Chronic Respiratory Failure with Hypoxia (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period, leading to persistently low levels of oxygen in the blood), Peripheral Vascular Disease (a condition that affects the blood vessels outside the heart 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, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 3 of 6 residents (Residents #10, Resident #15, and Resident #22) reviewed for urinary catheters. 1. The facility failed to ensure RCP O performed hand hygiene and changed gloves appropriately while providing incontinent/urinary catheter care to Resident #10. 2. The facility failed to ensure RCP O performed proper incontinent/urinary catheter care to Resident #10. 3. The facility failed to ensure Resident #15 had an indwelling (foley) catheter securement device on 2/10/25 and 2/11/25. 4. The facility failed to ensure Resident #22 had an indwelling (foley) catheter securement device on 2/10/25 and 2/11/25. 5. The facility failed to document Resident #22's indwelling (foley) catheter care on 1/05/25 (6am and 6pm), 1/18/25 (6am), 1/26/25 (6am), 2/03/25 (6am),…

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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #1) reviewed for nutrition. The facility failed to obtain Resident #1's weekly weights times 4 on admission. The facility failed to obtain Resident #1's readmission weight after her hospital stay (12/26/24-12/31/24). Resident #1 was readmitted on [DATE]. The facility failed to follow Resident #1's January 2025 dietary recommendation for the health shakes to be changed to house shakes (nutritional supplement for weight concerns) and given for 90 days. These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 01/10/25 indicated…

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 attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 of 10 residents (Resident #1) reviewed for bedrails. The facility failed to ensure informed consent for the use of Resident #1's bed rails were obtained prior to installation. The facility failed to obtain a bed rail assessment to assess the risk of entrapment for Resident #1's bed rails. These failures could place residents at risk of entrapment or injury. Findings included: Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Asperger's syndrome (is a term sometimes used to describe a developmental disorder that's part of the autism spectrum disorder (ASD)), epilepsy (is a chronic brain disorder characterized by recurrent seizures,…

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 each resident's drug regimen was free from unnecessary medications (is a medication used: in excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 2 of 5 residents (Resident #1 and Resident #11) reviewed for unnecessary medications. The facility failed to ensure Resident #1, and Resident #11 had monitoring for being on an antiplatelet. The facility failed to ensure Resident #1 had side effect monitoring for her anticonvulsant use. The facility failed to ensure Resident #1 had documented diagnoses entered for use of Lamotrigine (is a medication used to treat epilepsy and stabilize mood in bipolar disorder), Levothyroxine (is used to treat hypothyroidism), Minocycline (is an antibiotic that treats bacterial infections, Ondansetron (is used 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 interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 2 of 5 residents (Resident #1, Resident #11) reviewed for unnecessary medications. The facility failed to ensure Resident #1 had behavior (monitor activities and mood) and side effect (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) monitoring for her prescribed Sertraline (antidepressant; is used to treat depression). The facility failed to ensure Resident #11 had behavior monitoring for her prescribed Buspirone (antianxiety; is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) and Venlafaxine (antidepressant; is used to treat major depressive disorder, anxiety, and panic disorder). These failures could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic…

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 were free of significant medication errors for 2 of 13 residents (Residents #1 and Resident #93) reviewed for medication administration. The facility failed to ensure Resident #1's Protonix (is used to treat certain conditions in which there is too much acid in the stomach) was scheduled before meals for optimal desired results. The facility failed to ensure Resident #93's prescribed Midodrine (is used to treat low blood pressure (hypotension)) was not administered when her blood pressure was outside of the ordered parameters 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/10/25, and 2/11/25. The facility failed to ensure Resident #93 was administered Midodrine with meals per the physician's order. These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #1's face sheet dated 01/10/25 indicated Resident #1 was a [AGE]…

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 each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 18 residents (Resident #17) reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #17's request for an alternate meal choice for lunch service on 2/12/25 without state surveyor intervention. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #17's face sheet dated 2/12/25 revealed she was [AGE] years old and admitted to the facility initially on 3/02/17 and re-admitted [DATE]. Resident #17 had diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder. Record review of Resident #17's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 15, which indicated she was cognitively intact. The MDS indicated Resident #17…

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 18 residents (Residents #10) reviewed for infection control practices. 1. The facility failed to ensure RCP O performed hand hygiene and changed gloves appropriately while providing incontinent care/indwelling urinary catheter care to Resident #10. 2. The facility failed to ensure RCP O did not place a plastic bag onto Resident #10's low air loss mattress (that required no bed sheets) twice that fallen onto the floor twice while RCP O performed incontinent/urinary catheter care. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #10's face sheet dated 2/11/25 indicated she was [AGE] years old and 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 interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure injury. The facility failed to ensure RN E performed wound care to Resident #1's right heel DTI (deep tissue injury- pressure induced damage to underlying tissues to intact skin) per the physician's orders. The facility failed to ensure RN E applied kerlix (rolled gauze) and ace wrap (elastic wrap) appropriately to Resident #1's right foot/leg. These failures could place residents at risk for deterioration of wounds. Findings included: Record review of Resident #1's face sheet dated 10/29/24 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included diabetes (high blood sugar), pressure induced deep tissue damage of right heel,…

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 a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 5 residents (Residents #2) reviewed for urinary catheters. 1. The facility failed to ensure Resident #2 had an indwelling urinary catheter (tube inserted into the bladder to drain urine) securement/anchor device (used to secure an indwelling urinary catheter). 2. The facility failed to ensure CNA A performed hand hygiene and changed gloves appropriately while providing incontinent care/indwelling urinary catheter care to Resident #2. These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections. Findings included: 1. Record review of Resident #2's face sheet dated 10/30/24 indicated she was [AGE] years old and 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 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 2 of 5 residents (Resident #1 and Resident #3) reviewed for infection control. 1. The facility failed to ensure RN E followed the Enhanced Barrier Precautions (EBP) (interventions to prevent spread of infection in high-risk residents) policy of wearing a gown and gloves until she completed Resident #1's pressure ulcer wound care to his right heel. 2. The facility failed to ensure CNA D followed the EBP policy of wearing a gown while performing urinary catheter (tube inserted into the bladder to drain urine) care for Resident #3 who had a urinary catheter. 3. The facility failed to ensure CNA D changed her gloves after providing urinary catheter care to Resident #3 prior to touching Resident #3's clean catheter…

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 a safe, functional, sanitary, and comfortable environment to those residents who eat their meals in one of one dinning rooms. The facility failed to identify and rectify foul smells in the dining room. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: During an observation on 01/08/2024 at 10:30 a.m., it was observed that the dining room had a foul smell similar to the smell of sewage. During an interview and observation on 01/08/2024 at 11:00 a.m., Director of Plant Operations J stated that there were no drains that were backing up sewage in the facility. He said in the kitchen there was a drain cleaning solution that was pumped into a pipe while dishes were being washed. He said that was to ensure that the drainage pipe was cleaned and to prevent a smell from occurring. He said at the end of November 2023 and early December…

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, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 of 5 residents (Resident #19, Resident #25, and Resident #29) reviewed for unnecessary psychotropic medications (are medications that affect the mind, emotions, and behavior). The facility failed to ensure Resident #19 had behavior monitoring for her prescribed antianxiety (treats anxiety disorders), anticonvulsant (are prescription medications that help treat and prevent seizures), and antipsychotic (are the main class of drugs used to treat people with schizophrenia) medications. The facility failed to ensure Resident #19 had side effect monitoring for her prescribed antianxiety, anticonvulsant, and antipsychotic medications. The facility failed to ensure Resident #25 had an appropriate diagnosis…

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, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 15 residents (Resident #14) and 1 of 1 treatment carts reviewed for drug storage. The facility failed to securely store over the counter medication Neosporin for Resident #14. LVN D failed to securely lock the wound treatment cart. These failures could place residents at risk for adverse reactions. Findings included: 1. Record review of the face sheet 1/8/2024 indicated Resident #14 was [AGE] years old and was admitted on [DATE] with diagnoses including Ataxia (poor muscle control), Functional urinary incontinence (involuntary leakage of urine due to environment or physical barriers to toileting), History of falling, lack of coordination, and diabetes. Record review of the MDS dated [DATE] indicated Resident # 14 was usually understood and understood by others. Resident #14 indicated a BIMS score of 5 indicating Resident #14 was cognitively impaired. Resident #14 MDS indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 15 residents reviewed for dignity. (Resident #19) The facility failed to provide Resident #19 with a type of clothing protector (designed to protect clothing from mealtime mishaps) to ensure she did not have food on gown after eating. The facility failed to ensure Resident #19 was cleaned up promptly after meals. These failures placed residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including abnormal posture, dysphagia (difficulty swallowing), hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 15 residents (Resident #19 and Resident #242) reviewed for resident rights. 1. The facility failed to ensure Resident #19's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consents were completed properly upon admission and prior to the administration of Zyprexa ( antipsychotic medication that can treat several mental health conditions like schizophrenia and bipolar disorder), Venlafaxine ( used to treat major depressive disorder, anxiety, and panic disorder), Trazodone ( used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 15 residents (Resident #19) reviewed for reasonable accommodations. The facility failed to ensure Resident #19's call light was placed on her dominant side and hand without a contracture (is a fixed tightening of muscle, tendons, ligaments, or skin). This failure could place residents at risk for unmet needs. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including contracture, left hand and ankle, abnormal posture, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. Record review of Resident #19's quarterly MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility did not immediately notify the physician and resident representative of a significant change in in the resident's mental or psychosocial status for 1 of 15 residents (Resident #5) reviewed for resident rights. The facility failed to inform the attending Physician and the residents representative for Resident #5 when she barricaded herself in her room on 10/22/2023. This failure could place residents at risk for not receiving appropriate care and interventions. Findings included : Record Review of Resident #5 Face Sheet dated 1/8/2024 indicated Resident #5 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #5's diagnosis included Alzheimer's disease with late onset (progressive decline in episodic memory that begins after the age of 64), Dementia in other diseases classified elsewhere (general term for loss of memory, language, and problem-solving abilities), unspecified severity, without behavioral disturbances and other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 15 resident reviewed for assessments. (Resident #25) The facility failed to code Resident #25's fall on his MDS. This failure could place residents at risk of not having individual needs met. Findings included: Record review of Resident#25's face sheet printed on 01/09/24 indicated Resident #25 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including Parkinson's, Dementia, moderate, with other behavioral disturbance and fall on same level from slipping, tripping, and stumbling with subsequent striking against other objects. Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 was usually understood and usually had the ability to understand others. The MDS indicated Resident #25 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #25 was dependent for walking and substantial/maximal…

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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 resident's (Resident #34) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #34. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner. Findings included: Record review of face sheet dated 01/08/24 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting), dysphagia (difficulty swallowing), and lack of coordination. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS indicated a BIMS of 08 which indicated moderate…

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 individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #16) reviewed for PASRR Level 1 screenings. The facility failed to complete a PASRR Level 1 screening for Resident #16 following a discharge from a mental health hospital with a new diagnosis of mental illness. This failure could place residents at risk of not being evaluated for PASRR services and receiving needed services. The findings were: Record review of face sheet dated 01/09/24 revealed Resident #16 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Bipolar type (episodes of mania and sometimes depression) with an onset 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 interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one (Resident #192) of six residents reviewed for care plan completion. The facility failed to complete Resident #192's baseline care plan within the required 48-hour timeframe of admission. This failure could place residents who were admitted within the last 30 days at risk for not receiving necessary care and services or having important care needs identified. Findings included : Review of Resident #192's face sheet dated 12/29/2023 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including Senile Degeneration of the Brain (the mental deterioration or loss of intellectual ability), Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems), and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident #192's Baseline 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 15 residents reviewed for care plans. (Resident# 19, Resident #29) The facility failed to implement Resident #19's care plan intervention to off-load (is described as lifting or pushing an area of high pressure away from the cause of the pressure) her heels when in bed. The facility failed to care plan Resident # 19's diagnosis of Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and use of insulin (therapy often is an important part of diabetes treatment), diuretic (are medicines that help reduce fluid buildup in the body), opioid (sometimes called narcotics, are a type of drug), and antiplatelet (are medications that prevent blood clots from forming) coded of her MDS. The facility failed to care plan Resident #19's use of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 15 residents (Residents #34), reviewed for care plans. The facility failed to revise and update Resident #34's comprehensive care plan for an anticoagulant medication (a medication that helps prevent blood clots). This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of face sheet dated 01/08/24 indicated Resident #34 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of myotonic muscular dystrophy (a genetic condition that causes progressive muscle weakness and wasting), dysphagia (difficulty swallowing), and atrial flutter (a type of abnormal heart rhythm). Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 resident reviewed for ADLs. (Resident #19) The facility failed remove Resident #19's unwanted facial hair. The facility failed to provide Resident #19 her schedule bath/showers. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side and muscle weakness. Record review of Resident #19's quarterly MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 4 residents (Resident #19) reviewed for range of motion and mobility The facility failed to ensure Resident #19 had on a hand device. This failure had the potential to affect resident with limited ROM by placing them at risk for a decline in their functional abilities. Findings included: Record review of Resident #19's face sheet printed 01/09/24 indicated Resident #19 was a [AGE] year-old female and admitted on [DATE] with diagnoses including contracture, left hand and ankle, abnormal posture, hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting left no-dominant side, and muscle weakness. Record review of Resident #19's quarterly MDS assessment dated [DATE] indicated…

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 received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Resident #23) who were reviewed for indwelling urinary catheter care. The facility failed to ensure CNA F followed appropriate procedures and infection control during foley catheter care for Resident #23. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #23's face sheet dated 1/09/23 indicated Resident #23 was a [AGE] year-old female and admitted on [DATE] with diagnoses including paralytic syndrome (unable to move) following a cerebrovascular disease (problem with blood flow to the brain causing damage to the brain), paraplegia (complete or partial loss of muscle function to all or part of the trunk, legs, or pelvic organs), reduced mobility, and hypertension (high blood pressure). Record review of Resident #23's quarterly MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 15 residents reviewed for respiratory care. (Resident #13 and Resident #19) 1.The facility failed to ensure Resident #13's yankauer suction catheter (hard-plastic tip with handle used to suction secretions from the mouth) was properly stored. 2. The facility failed to ensure Resident #19 had a filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient is of high quality) in the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe). 3. The facility failed to ensure Resident #19's compartment that held the oxygen concentrator filter did not have white, fuzzy material. These failures could place residents at risk of respiratory complications or respiratory infection. Findings included: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed for transmission-based precautions. (Resident #6 and Resident #9) The facility failed to isolate Resident #6 and Resident #9 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine. This failure could place residents at risk for being exposed to health complications and infectious diseases. Findings included: 1. Record review of Resident #6's face sheet printed on 01/10/24 indicated Resident #6 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (a progressive decline in a person's ability to think and remember can be due to a wide range of brain…

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.