Longview Hill Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure treatment was provided, consistent with professional standards of practice, to prevent new pressure injuries from developing for 2 of 4 residents reviewed for pressure injuries (ulcers). (Resident #1, Resident #2)1. The facility failed to complete weekly skin assessments for Resident #1 since 01/27/26. 2. The facility failed to complete quarterly Braden Scale Assessments on Resident #1 and Resident #2. There were no quarterly Braden Scale Assessments for Resident #1 since 06/04/25 and for Resident #2 since 02/08/24.These failures could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries.1. Record review of a face sheet dated 02/28/26 indicated Resident #1 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of heart failure, muscle weakness, and diabetes. The face sheet indicated Resident #1 had been discharged to an acute care…

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 resident or the resident's representative had the right to access all records pertaining to the resident, including current clinical records, within 24 hours (excluding weekends and holidays) upon oral or written request, and to obtain copies of such records within two working days upon request for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility did not provide Resident #1's MPOA access to Resident #1's urinalysis (UA) lab results in December 2025 when she verbally requested access. This failure could place residents at risk for delayed medical decision-making, lack of informed consent, and potential harm due to the representative's inability to timely review laboratory results and participate in care planning.Findings included: Record review of an admission record dated 02/07/26 indicated Resident #1 was a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 2 residents (Resident #1) reviewed for abuse. The facility failed to thoroughly investigate an allegation of abuse reported to the Administrator regarding Resident #1 on 08/25/25. The Administrator did not interview Resident #1, her representative, or the caregiver that verbalized the allegation of abuse. These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and injuries of unknown source.Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female, admitted to the facility on [DATE], and discharged on 08/25/25. Her diagnoses included dementia (a general term for a decline in mental ability that affects memory, thinking, and social skills to the point of interfering with daily life). Record review of the facility's Provider Investigation Report, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs to meet the needs of residents for 5 of 6 residents reviewed for medication administration. (Resident #3, Resident #4, Resident #5, Resident#6, and Resident #7.) Resident #3 had insulin that was past the 28-day labeled precautionary instructions. LVN E was going to administer the mediations. After she noted the insulin was past the 28- days, she had difficulty finding the correct medications. Residents # 4 # 5, and #7 had insulin in the medication cart that was past the 28-day labeled precautionary instructions. Resident #6's insulin had a space on the box for an opened date but there was not a date listed. These failures could place residents to receive medications that were not effective to control diabetic symptoms. Findings included: 1. Record review of Resident #3's face sheet dated 2/13/25 indicated he 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were sealed and dated. 2. Hair restraints were worn appropriately by dietary staff. These failures could place residents at risk for foodborne illness. Findings included: During an initial tour observation in the kitchen on 01/13/2025 at 9:30 a.m. there were 2 undated containers of instant mashed potatoes in the dry storage, 1 unsealed box of biscuit in the freezer. During an observation in the kitchen on 01/13/2025 at 9:40 a.m., [NAME] W was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] W's hair was visible outside of the hairnet in the back approximately four inches. During an observation in the kitchen on 01/14/2025 at 11:15 a.m., [NAME] W was not wearing a hair restraint appropriately while preparing the lunch meal. [NAME] W's hair was visible outside of the hairnet in the back approximately…

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 care plan to meet the medical, nursing, mental and psychosocial needs for 4 of 34 residents (Resident #17, Resident #21, Resident #79, and Resident #110) reviewed for care plans. 1. The facility failed to care plan Resident #17's verbal and other behavioral symptoms, the diagnosis of COPD (is a chronic lung disease that makes it difficult to breathe) and use of an antiplatelet medication (work to make your platelets less sticky and thereby help prevent blood clots from forming in your arteries). 2. The facility failed to care plan Resident #110's use of an antiplatelet medication, risk for pressure ulcers (is a localized area of skin damage caused by prolonged pressure on the skin), and the diagnosis of dehydration (occurs when your body loses more water and fluids than it takes in). 3. The facility failed to ensure a care plan was developed and implemented for Resident #21's use of dentures. 4. 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 each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 3 of 6 residents reviewed for unnecessary medications. (Resident #66, Resident #71, and Resident #78) The facility failed to ensure Resident #66 did not receive an antibiotic, Cephalexin 250mg BID for an UTI, without appropriate lab work. The facility failed to ensure Resident #71's antibiotic, Macrobid 100mg BID, was discontinued after her urine culture (checks urine for germs (microorganisms) that cause infections) results showed no organism growth. The facility failed to ensure Resident #78 did not receive antibiotics, Rocephin (Ceftriaxone) 2gm IM 1 time dose and Levaquin (Levofloxacin) 750mg one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring and diagnosis) for 3 (Resident # 17, Resident #23, and Resident #110) of 5 residents whose medications were reviewed. The facility failed to ensure Resident #17's behaviors were documented to justify her Wellbutrin (is a prescription medicine used to treat adults with a certain type of depression called major depressive disorder, and for the prevention of [NAME]-winter seasonal depression (seasonal affective disorder)) dosage increase on 11/22/24. The facility failed to ensure Resident #23 had behavior and side effect monitoring for her prescribed anticonvulsant, Depakote. The facility failed to ensure Resident #110 had side effect monitoring for her prescribed Trazadone. These failures could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications and unnecessary medication use.…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 7 of 28 residents (Resident's #10, #13, #17, #34, # 60, # 86 and #101) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #10, Resident #13, Resident #34, Resident #60, Resident #86 and Resident #101, who complained the food was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 01/13/2025 at 10:54 a.m., Resident #34 stated the food was terrible, no taste at all. During an interview on at 01/13/2025 11:08 a.m., Resident #60 stated the food was not good, it had no flavor. During an interview on 01/13/25 at 11:15 a.m., Resident #17 said the flavor and temperature of the food was not good sometimes. During an interview on 01/13/2025 at 11:16 a.m., Resident #86 stated the food was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #66 and Resident #17) reviewed for resident rights. 1. The facility did not ensure CNA Q and CNA R explained the procedure before initiating the transfer and incontinent care provided on 12/21/2024 to Resident #66. 2. The facility failed to provide scheduled smoke breaks for Resident #17 who resided on the memory care, secured unit. The failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: 1. Record review of Resident #66's face sheet, dated 01/15/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #66 had diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), protein-calorie malnutrition (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 17 residents reviewed for the right to be informed. (Resident #68, Resident #79, and Resident #108) 1. The facility failed to ensure Resident #68'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 Abilify (antipsychotic medication used to treat certain mental/mood disorders) as evidenced by there was no clinical indications for use, no dosage or frequency, and no side effects, risks, or benefits listed for the proposed treatment. 2. The facility failed to ensure Resident #68's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 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 provide a safe, clean, and comfortable homelike environment for 1 of 4 residents (Resident # 21) reviewed for a homelike environment. The facility failed to ensure Resident #21's floors were free of debris, dust, and shreds of papers. The facility failed to ensure Resident #21's dresser was free from a white creamy substance on the top flat surface, side of dresser and front of the dresser. The facility failed to ensure Resident #21's bathroom cabinet was clean from a dried sticky red liquid . The facility failed to ensure Resident #21's personal refrigerator door was free from white splattered dried substances. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of the face sheet dated 01/15/2025 indicated, Resident #21 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included cerebrovascular…

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 of the residents to be free from abuse for 1 of 4 residents (Resident #66) reviewed for abuse. The facility failed to keep Resident #66 free from abuse when CNA Q and CNA R roughly provided mechanical lift transfer and incontinent care to her on 12/21/2024. This failure could place residents at risk of abuse, creased resistance to care, increased agitation, skin tears, soreness, and injury Findings included: Record review of Resident #66's face sheet, dated 01/15/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #66 had diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), protein-calorie malnutrition (the state of inadequate intake of food), muscle wasting, lack of coordination and cognitive communication deficit. Record review of Resident #66's Quarterly MDS assessment, dated 12/04/2024, reflected Resident #66…

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 notify the resident and the resident's representative of the transfer or discharge and the reasons for the transfer or discharge in writing at least 30 days before the resident is transferred or discharged or as soon as practicable before transfer or discharge when a resident has not resided in the facility for 30 days for 1 of 1 resident (Resident #169) reviewed for transfer and discharge. The facility failed to provide Resident #169's representative with a written 30-day discharge notice with a reason of discharge. This failure could place residents at risk of improper discharge planning and diminished quality of life. Findings included: Record review of Resident #169's face sheet dated 01/15/2025 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of acute respiratory failure with hypoxia (difficulty breathing), congestive heart failure (the heart does not pump efficiently), cognitive communication…

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 assessments accurately reflected the resident status for 1 of 34 residents (Resident #79) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #79 was receiving Quetiapine Fumarate (Seroquel), an antipsychotic medication (used to treat certain mental/mood disorders). These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #79's face sheet dated 1/14/25 revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #79 had diagnoses including depressive episodes, anxiety disorder, multiple rib fractures (broken bones), repeated falls, lack of coordination, shortness of breath, heart failure, and high blood pressure. Record review of Resident #79's admission MDS assessment dated [DATE] indicated she had a BIMS of 13, which indicated she was cognitively intact. The MDS indicated Resident #79…

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 #39) reviewed for PASRR Level I screenings. Resident #39's PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses major depressive disorder were diagnosed on [DATE] . 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 #39's face sheet, dated 10/2/13 , indicated he was an [AGE] year-old male, admitted to the facility on [DATE], and readmitted most recently on 05/31/24 . His diagnoses included major depressive disorder (A mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (Mental health conditions that cause excessive 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 observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receive the necessary services to maintain grooming and personal hygiene for 3 of 28 residents reviewed for ADLs. (Resident #5, Resident #46, and Resident #51) The facility did not ensure Resident #5, Resident # 46, and Resident # 51 did not have chin hair on 01/13/2025 and 01/14/2025. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem. The findings included: 1.Record review of the face sheet, dated 10/17/2024, revealed Resident #5 was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of multiple sclerosis ( a chronic disease that damages the central nervous system), unspecified dementia ( general term for dementia that doesn't have a specific diagnosis), muscle weakness ( a lack of muscle strength 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 observations, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accidents (Resident #66). The facility failed to ensure a safe environment when CNA Q and CNA R walked away and left Resident #66 unsupervised at bedside during a mechanical lift transfer on 12/21/2024. This failure could place residents at risk of injuries, falls and hospitalizations. Findings include: Record review of Resident #66's face sheet, dated 01/15/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #66 had diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), protein-calorie malnutrition (the state of inadequate intake of food), muscle wasting, lack of coordination and cognitive communication deficit. Record review of Resident #66's Quarterly MDS assessment, dated 12/04/2024, reflected Resident #66…

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 9 residents (Resident #23) reviewed for nutrition. The facility failed to follow the dietician's recommendation to increase Resident #23's Med Pass 120ml TID to QID ordered on 11/15/24 and 12/06/24. This failure placed resident at risk for malnutrition and weight loss. Findings included: Record review of Resident #23's face sheet dated 01/13/25 indicated Resident #23 was an 86-years-old female admitted to the facility on [DATE]. Resident #23 had diagnoses including dementia (is a general term for a decline in mental abilities that affects a person's ability to perform everyday activities), protein-calorie malnutrition (refers to a nutritional status in which reduced availability 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 provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 28 residents (Resident #17) reviewed for pharmacy services. The facility failed to ensure Resident #17's Wellbutrin (is a prescription medicine used to treat adults with a certain type of depression called major depressive disorder, and for the prevention of [NAME]-winter seasonal depression (seasonal affective disorder)) SR Oral Tablet Extended Release 200mg was available for administration on 10/13/24, 10/14/24 and 11/04/24. This failure could place residents at risk for inaccurate drug administration. Findings included: Record review of Resident #17's face sheet dated 01/13/25 indicated Resident #17 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #17 had diagnoses including dementia (is the loss of cognitive functioning - thinking, remembering, 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, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 9 med carts and 2 of 36 Residents (Resident #10, Resident # 39) reviewed for medication storage. 1.The facility failed to securely store prescription medication Nystop powder 100,000 units and Venelex 60-gram ointment for Resident #10. 2. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #39 had a medication cup, with approximately 10 medications in pill form in it, sitting on his bedside table. 3. The facility failed to ensure CMA J secured the medication cart for Hall 200. These failures could place residents at risk for health complications and not having received the intended therapeutic benefit of their medications and adverse reaction. Findings included: 1.Record review of the face sheet dated 1/15/2025 indicated Resident #10 was [AGE] years old and was readmitted on [DATE] 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, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #61). The facility failed to ensure the refrigerator for Resident #61 did not contain spoiled milk and the surfaces were clean. This failure could place resident at risk for food borne illnesses. Findings included: Record review of a face sheet dated 01/25/22 indicated Resident #61 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Paranoid Schizophrenia (A person believes something that is not real is real. For example, they may believe that people are trying to harm them), Dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), and Dementia (a general term for a group of neurological conditions that affect the brain and cause a decline in mental abilities).…

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 4 residents (Resident #51 and Resident #66). 1. LVN G failed to use enhanced barrier precautions by donning a gown when performing gastrostomy tube feeding on Resident #51. 2. CNA Q and CNA R failed to change their gloves while performing incontinent care on Resident #66 and touched the resident and clean surfaces with soiled gloves . These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of a face sheet dated 01/14/2025 indicated Resident #51 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included unspecified dementia, unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen (14) days for 2 of 4 residents reviewed for unnecessary medications review. (Residents #1 and #2). 1.Resident #1 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. 2. Resident #2 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary psychotropic medications . Findings included: 1.Record review of the undated face sheet indicated Resident #1 was a [AGE] year-old female that admitted [DATE]. Her diagnoses included: unspecified dementia with other behavioral disturbance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines for 2 of 2 observed meals reviewed for meal accuracy. The facility failed to ensure there was 7 days' worth of food available from 09/01/2024 through 09/03/2024 to prepare and serve their planned and/or alternate menu on 09/01/2024 through 09/03/2024 for breakfast, lunch, and dinner. This deficient practice could place residents at increased risk for inadequate nutrition. Findings included: During an observation on 09/02/2024 at 12:19 PM, in the facility's main dining room, revealed the following: -Lunch served was ½ of a grilled cheese sandwich, 1 bowl of vegetable soup, and a piece of German chocolate cake. -Dry pantry revealed: (2) 6.56-pound cans of corn, (2) 104-ounce cans of sliced apples, (1) 6.12 pound can of black beans, (10) 14.5-ounce cans of diced red peppers, (11) 35-ounce bags of dry cereal, (1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for notification of change. The facility failed to notify Resident #1's NP when she had a worsening of her skin conditions. This failure could result in residents not receiving treatments, supplements, or medications to maintain health. Findings included: Record review of a face sheet dated 02/24/2024 indicated Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute pyelonephritis (sudden and severe infection of the kidney due to a bacterial infection), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), and diabetes mellitus due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 4 residents (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2's call light was answered promptly by LVN A. This failure could place residents at risk of injury from accidents and hazards. Findings included: Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included fracture of unspecified part of left clavicle (collarbone), displaced fracture of coracoid process (fracture of a part of the shoulder), left shoulder, multiple fractures of ribs, bilateral, and unspecified fracture of unspecified thoracic vertebra (back bone fracture). Record review of the electronic health record on [DATE] indicated Resident #2 did not have an MDS assessment due to recent…

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 medical record was complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A accurately documented on Resident #1's February 2023 MAR. The facility failed to ensure LVN B and LVN C documented accurate skin assessments for Resident #1. These failures could place residents at risk of pressure injuries, medication errors, and not receiving medications and required treatments as ordered by the physician. Findings included: Record review of a face sheet dated 02/24/2024 indicated Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute pyelonephritis (sudden and severe infection of the kidney due to a bacterial infection), paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), and diabetes mellitus due to underlying condition without…

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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 4 residents (Resident #2) reviewed for call lights. The facility failed to ensure Resident #2's call light was functioning properly. This failure could place residents at risk of injury, falls, and unmet needs. The findings included: Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included fracture of unspecified part of left clavicle (collarbone), displaced fracture of coracoid process (fracture of a part of the shoulder), left shoulder, multiple fractures of ribs, bilateral, and unspecified fracture of unspecified thoracic vertebra (back bone fracture). Record review of the electronic health record on [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.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Hamburger meat was thawed improperly. 2. The paper towel dispenser was empty at the handwashing station. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on 11/27/23 at 9:00 a.m., it was observed that the handwashing station did not have a way to dry hands as the paper towel dispenser was empty. Surveyor was unable to dry their hands after washing upon entry. It was observed that hamburger meat, approximately 10-20 pounds, was thawing on top of a table uncovered in a large metal container. Over the course of the initial tour, approximately 20 minutes, the hamburger meat was not handled or prepared by staff . During an interview on 11/29/23 at 11:15 a.m. with the Director of Nursing, she said kitchen staff should thaw meat according 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 interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 2 residents reviewed for misappropriation of property. (Resident #15) The facility failed to prevent a diversion (misappropriation) of Resident #15's Hydrocodone-Acetaminophen (Norco) 7.5-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on 11/4/23 and 11/27/23. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings included: Record review of Resident #15's face sheet dated 11/27/23 indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and 06/28/22 with diagnoses including pain in unspecified joint and chronic pain syndrome (occurs when pain remains long after an illness or injury has healed). Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated Resident #15 was understood and had the ability to understand…

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 care plan to meet the medical, nursing, mental and psychosocial needs for 4 of 24 residents reviewed for care plans. (Resident #44, Resident #89, Resident #98, and Resident #106) The facility failed to implement fall prevention intervention of fall mats at bedside for Resident #44. The facility failed to implement the care plan intervention for Resident #89 to administer wound care treatment as ordered. The facility failed to develop care plan interventions after Resident #98 had a fall. The facility failed to ensure LVN B performed Resident #106's wound care to multiple wounds as ordered by the physician per the care plan. These failures could place residents at risk of not having their individualized needs met in a timely manner and could result in a decline in physical well-being and care needs not being addressed. Findings included: 1. Record review of Resident #44's face sheet dated 11/27/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 6 of 24 residents (Resident #38, #61, #7, #56, #82 and #90) reviewed for ADLs. The facility failed to provide oral care for Resident #38 and #61. The facility failed to provide scheduled showers and/or bed baths to Resident #7, Resident #56, Resident #82, and Resident #90. The facility failed to provide nail care to Resident #56 and Resident #90. The facility failed to removal facial hair from Resident #56. The facility failed to provide scheduled hair washing for Resident #82. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings include: 1. Record Review of Resident #38's face sheet revealed a 91-year- old female who was admitted to the facility on [DATE] with diagnoses of Alzheimer's, gastrostomy (an opening into the stomach from the abdominal wall, made…

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 needed respiratory care were provided such care, consistent with professional standards of practice for 6 of 10 residents (Resident #7, # 14, # 18, # 20, # 23, and Resident # 82) reviewed for respiratory care in that: The facility failed to ensure Resident #7 had water in his humidification canister (aids in preventing a patient's airways from becoming dry). The facility failed to ensure Resident #7 nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. The facility failed to ensure Resident #7, Resident #23, and Resident #82's nasal cannula (is a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) were labeled and dated. The facility failed to ensure Resident #14, Resident #18, and Resident #20 had oxygen concentrator filters (are used within the machine to remove particles and contaminants from entering your lungs for an improved therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 2 of 4 licensed staff (LVN W, LVN N) reviewed for nursing competencies. The facility failed to ensure LVN W and LVN N followed Resident #88's physician orders to not give Novolog (is a fast-acting injectable insulin that can be prescribed for people with Type 1 or Type 2 diabetes) when blood glucose results were less than 120. This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing accidents from procedural errors and errors in medication administration. Findings included: Record review of Resident #88's face sheet dated 11/28/23 indicated Resident #88 was [AGE] year-old female and admitted on [DATE] and 08/31/23 with a diagnosis of Type 2 diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs for 1 of 2 medication rooms reviewed for storage of medication. (Medication room [ROOM NUMBER]) The facility failed to ensure the narcotic box was permanently affixed inside the refrigerator in Medication room [ROOM NUMBER]. This failure could place residents that take narcotics that required refrigeration at risk of misappropriation of drugs. Findings included: During an observation and interview on 11/28/23 at 1:20 PM, ADON A went in Medication room [ROOM NUMBER] with this surveyor. She unlocked the Medication room [ROOM NUMBER] door, then opened the small unlocked refrigerator which contained a metal-type box with a handle. The refrigerator was not locked and did not have a lock on it. The (locked) box inside the refrigerator was not secured or affixed to the small refrigerator. ADON A said the narcotic box used to be attached 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 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 3 residents reviewed for dignity. (Resident #89) The facility failed to provide Resident #89 a privacy bag (helps maintains dignity of catheterized patients by restoring a sense of privacy) for his suprapubic catheter bag (collects urine by attaching to a drainage bag). This failure placed residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of a face sheet dated 11/28/23 indicated Resident #89 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE], with diagnoses including paraplegia (is a specific pattern of paralysis (which is when you can't deliberately control or move your muscles) that affects your legs), pressure ulcer of left buttock, sacral region, and right buttock, stage 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the residents had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 1 (Resident #82) of 22 residents reviewed for care planning. The facility failed to schedule Resident #82's care plan meeting on a non-dialysis day (Mondays, Wednesdays, and Fridays) so she could attend. This failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings included: Record review of Resident #82's face sheet dated 11/27/23 indicated Resident #82 was a [AGE] year-old female and admitted on [DATE] and 08/04/23 with diagnoses including acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood), congestive heart failure (the heart's capacity to pump blood cannot keep up with the body's need), end stage renal…

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 immediately consult with the resident physician when there was significant change in the resident physical condition for 1 of 4 residents reviewed for change in condition. (Resident #88) The facility failed to notify MD U of Resident #88's elevated blood sugar glucose. This failure could result in diabetic residents not receiving appropriate treatment for elevated blood sugars. Findings included: Record review of Resident #88's face sheet dated 11/28/23 indicated Resident #88 was [AGE] year-old female admitted on [DATE] and 08/31/23 with a diagnosis of Type 2 diabetes mellitus (is a disease that occurs when your blood glucose, also called blood sugar, is too high.) with hyperglycemia (happens when there's too much sugar (glucose) in your blood). Record review of Resident #88's quarterly MDS assessment dated [DATE] indicated Resident #88 was understood and understood others. The MDS indicated Resident #88 had a BIMS score of 14 which indicated intact…

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 for 2 of 6 residents (Resident #22 and Resident #89) reviewed for environment. The facility failed to ensure Resident #22's room did not have peeling ceiling plaster (room [ROOM NUMBER]). The facility failed to ensure Resident #89's bathroom did not have plumbing issue and a warped vanity (room [ROOM NUMBER]). These failures placed resident at risk for diminished quality of life, harm, injury, and falls. Findings included: During an interview and observation on 11/27/23 at 11:34 a.m., Resident #22 said she did not like the peeling ceiling plaster by her door. She said it made her nervous it was going to fall on her. She said the area started small then got bigger. She said it had been like that since she moved into the room [ROOM NUMBER]-4 months ago. Resident #22 was sitting in her wheelchair by the room's door. On Resident #22's ceiling, a small area popcorn ceiling…

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 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 #11) reviewed for PASRR Level 1 screenings. The facility failed to complete a PASRR Level 1 screening for Resident #11 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 Resident #11's face sheet, dated 11/27/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #11's had diagnoses which included dementia, bipolar (mental disorder that is characterized by mood swings that last more than 2 weeks), and depression (state of sadness). Record review of Resident #11's MDS dated [DATE] revealed Resident #11 had a BIMS of 07, which 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 has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 2 of 2 residents (Resident #36, Resident #89) and 4 of 4 staff (CNA O, CNA S, CNA R, and CNA AA) reviewed for transfer. The facility failed to ensure CNA O, CNA S, CNA R, and CNA AA performed a safe mechanical lift transfer (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) for Resident #36 and Resident #89. This failure could place residents at risk of injury from accident and hazards. Findings included: 1. Record review of Resident #36's face sheet dated 11/29/23 indicated Resident #36 was a [AGE] year-old male and admitted on [DATE] and 02/26/20 with diagnoses including paraplegia (is a term used to describe the inability to voluntarily move the lower parts of the body), reduced…

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 dialysis service were provided consistently with professional standards of practice for 1 of 3 resident reviewed for dialysis services. (Resident #82) The facility failed to consistently document Resident #82's dialysis communication form. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #82's face sheet dated 11/27/23 indicated Resident #82 was a [AGE] year-old female and admitted on [DATE] and 08/04/23 with diagnoses including acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood), congestive heart failure (the heart's capacity to pump blood cannot keep up with the body's need), end stage renal disease (is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant), type 2 diabetes mellitus (is a condition that happens…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety. (Resident #62). The facility failed to ensure the refrigerator for Resident #62 did not contain expired foods. This failure could place resident at risk for food borne illnesses. Findings include: Record review of a face sheet dated 08/29/2023 indicated Resident #62 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Contracture of the right hand (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Acute Kidney Failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few day.) Record review of a Quarterly MDS dated [DATE] indicated Resident #62 understood others 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 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 1 of 24 residents reviewed for infection control. (Resident #112) The facility failed to ensure LVN B performed proper hand hygiene while performing wound care for Resident #112. The facility failed to ensure LVN B change residents soiled linens before allowing resident to return to bed after clean wound dressing applied to his posterior buttocks. These failures could place residents and staff at risk for cross- contamination and the spread of infection. Findings included: Record review of Resident #112's face sheet dated 11/29/2023 indicated Resident #112 was a [AGE] year old male admitted on [DATE], with the diagnosis including Cardiomegaly (A condition with bigger (enlarged) heart than the normal.), Hidradenitis suppurativa (A long-term…

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 all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 6 resident wheelchairs reviewed for essential equipment. (Resident #20 and #54) The facility failed to ensure Resident #20's wheelchair had a non-functioning left break. The facility failed to ensure Resident #54's wheelchair had two non-functioning breaks. This deficient practice could result in resident falls and injury while using their wheelchairs. Findings included: 1. Record review of a face sheet dated 11/27/2023, revealed Resident #20 was a [AGE] year-old female that admitted to the facility on [DATE]. Resident #20 had diagnoses of DM II (A chronic condition that affects the way the body processes blood sugar (glucose), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and emphysema (develops over time and involves the gradual damage of lung tissue, specifically the destruction of the alveoli…

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.