Lakeside Rehabilitation And Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 2 (Resident #43 and Resident #49) of 22 residents reviewed for comprehensive care plan revisions.1. The facility failed to ensure Resident #43's comprehensive care plan was updated with the most current information for the resident's smoking status. 2. The facility failed to ensure Resident #49's comprehensive care plan was updated with the most current information for the resident's smoking status. These failures could put residents at risk of not receiving the appropriate care, services, or treatments needed to maintain health.1. Record review of the admission record for Resident #43, dated 06/23/2026 revealed a [AGE] year-old female with an original admission date of 01/16/2022. Resident #43 had diagnoses which included: atherosclerotic heart disease (a heart condition affecting blood supply to the heart), congestive heart failure (a heart condition where the heart is too weak to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #49) reviewed for smoking. The facility failed to ensure Resident #49's smoking items were kept at the nursing station and he received adequate supervision while smoking. This failure could place the residents at risk of inadequate supervision, accidents, and burns which could result in injury.Findings Included: Record review of the admission record for Resident #49, dated 06/24/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: urinary tract infection (bacteria in urinary system), muscle weakness, and other lack of coordination. Record review of the admission MDS assessment for Resident #49, dated 12/28/25, revealed Resident #49 had a BIMS score of 14 indicating his cognition was intact. The MDS further revealed Resident #49 currently used tobacco.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents fed by gastrostomy tube (g-tube) (Resident #42), in that: The facility failed to ensure Resident #42's feeding pump was hooked up and infusing at the time ordered by the physician. This failure could result in weight loss and dehydration in residents with a g-tube.The findings included: Record review of the admission record for Resident #42, dated 06/24/26, revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: athetoid cerebral palsy (condition caused by early brain damage), muscle wasting and atrophy (muscles shrink and weaken) and gastrostomy status (g-tube). Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 22 residents reviewed for unnecessary medication (Resident #10).The facility did not monitor Resident #10 for side effects of the anticoagulation medication Apixaban.This failure could place the residents at risk for adverse consequences of medication.Findings included:Record review of Resident #10's face sheet, dated 06/24/2026, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include quadriplegia (paralysis all 4 extremities), seizures (episode of abnormal [NAME] activity), and hypertension (high blood pressure).Record review of Resident #10's Quarterly MDS Assessment, dated 04/24/2026, revealed Resident #10 had a BIMS score of 15, which revealed the resident's cognition was intact. Section N - Medications revealed Resident #10 received anticoagulant during the last 7 days. Record review of the physician orders dated 06/24/2026…

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 its medication error rate was less than 5 percent. The facility had a medication error rate of 10.34 percent based on 3 errors out of 29 opportunities, which involved 2 (Resident #8 and Resident #43) of 3 residents reviewed for medication administration. 1. MA E failed to give Resident #43's dose of the medication Chlorhexidine Gluconate at the ordered time, due to not having the medication available, resulting in a missed dose. 2. MA E failed to give Resident #8's doses of the medications Apixaban and Propranolol Hydrochloride at the ordered time, resulting in a late dose for each medication. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and a decline in health.1. Record review of Resident #43's admission Record dated 06/23/2026 revealed a [AGE] year-old female with an original admission date of 01/16/2022. Resident #43 had diagnoses which included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 of 4 residents (Resident #42) reviewed for infection control. RN A failed to wear proper PPE (a gown) when providing wound care and administering tube feeding through a PEG tube) for Resident #42 who was on EBP. These failures could place residents at risk for the spread of infection and cross contamination.Record review of Resident #42's admission record dated 06/25/2026, revealed a [AGE] year-old male with an original admission date of 07/16/2012. Resident #42 had diagnoses which included: athetoid cerebral palsy (a neurological condition caused by brain damage before or during birth), gastrostomy (a surgical procedure that creates a small opening through the abdominal wall into the stomach), and muscle…

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 that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents and establishes a system of records of receipt and disposition of all drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident reviewed for pharmaceutical services in that: The facility failed to have a system in place to ensure proper reconciliation of medications that would prevent missing medications for Resident #1. This failure could place residents at risk of having their medications diverted and/or receiving the incorrect dosage because due to staff not counting mediations in the narcotics refrigerator.Findings included: Record review of Resident #1's face sheet dated 03/30/2026, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: Unspecified diastolic (congestive) heart failure (heart's left…

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's bedside, toilet, and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff area for 1 of 5 residents (Resident #2 ) reviewed for resident call system.The facility failed to ensure Resident #2's call light was within reach while he was positioned in his bed.This failure could place residents at risk of not being able to call for assistance in emergency situations, a delay in care and services, and increased risk of falls and/or injuries. Findings include: Record Review of Resident #2's face sheet, dated 3/30/2026, revealed an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of cognitive functioning,…

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 maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise, for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to implement interventions to ensure that Resident #1 did not have a significant weight loss of 16.8 pounds, a 10% body weight loss, between 12/03/2026 and 01/16/2026. This failure could place residents at risk for decreased nutritional status, malnutrition, and a decline in health.Record review of Resident #1's face sheet dated 02/04/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: compression fracture of lumbar vertebra (fracture of a spinal bone in the lower back), Type 2 Diabetes Mellitus (a disease resulting in inadequate control of glucose in the blood), osteoporosis (a disease 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, interview, and record review, the facility failed to keep the resident's free of physical and chemical restraints that were not medically indicated for 1 of 15 residents (Resident #1) observed for physical restraints in that; The facility failed to ensure Resident #1 had a physician order, consent and evaluation for a chest restraint used for positioning and mobility. This failure could place residents at risk of injuries or entrapment. Findings include: Review of Resident #1's admission record, dated 10/09/25, revealed he was a 25 -year-old male admitted on [DATE] with the following diagnoses: spastic quadriplegic cerebral palsy (a type of cerebral palsy that affects all four limbs, causing stiffness, tightness, and difficulty with movement) and a history of falling. Review of Resident #1's quarterly MDS assessment, dated 08/29/25 revealed staff performed an assessment for mental status and Resident #1's cognitive skills for daily decision making were moderately impaired. The MDS further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure allegations of abuse were promptly and thoroughly investigated for 7 of 14 residents (Resident #1, #3, #4, #6, #8, #9, and #12) reviewed for abuse prevention. 1) Resident #1 alleged the Administrator made an obscene hand gesture. Resident #1 was not interviewed regarding the allegation and the incident was not reported to the State Agency as required. 2) Residents #3, #4, #6, #8, #9, and #12 alleged staff members were rude and/or yelled at them. The residents' allegations were documented on the Safe Surveys conducted on 05/08/25, the facility did not initiate an investigation on any of the residents' statements. These failures placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care. Findings included: Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis 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, observation, and record review, the facility failed to ensure dignity was maintained for 1 of 14 residents (Resident #1) reviewed for respect and dignity. The Administrator failed to respect and ensure Resident #1's dignity when he made an obscene hand gesture towards the resident. This failure placed residents at risk for loss of self-worth and emotional distress and failed to ensure the residents' right to be treated with dignity and respect.Findings included: Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there 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 interview, observation, and record review, the facility failed to ensure an allegation of abuse was reported immediately to the State Agency as required for 1 of 14 residents (Resident #1) reviewed for abuse reporting. Resident #1 alleged the Administrator made an obscene hand gesture. The allegation was not reported to the State Agency. This failure resulted in the residents' right to be free from abuse not protected, eliminated the opportunity for a timely investigation by the State Agency and placed all the residents at risk for abuse and psychological harm, which resulted in substandard quality of care. Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively…

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, observation, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for narcotic medication being accounted for. 1. LVN A failed to document Resident #1's Oxycodone/Acetaminophen 10/325MG on the MAR after administration. 2. LVN B & RN C failed to document Resident #1's Oxycodone/Acetaminophen 10/325MG on the Narcotic Record Count Sheet after administration. 3. LVN B failed to notify the DON of a discrepancy with Resident #1's Oxycodone/Acetaminophen 10/325MG per facility policy. These failures could place residents at risk for not receiving prescribed medication. Findings include: Record review of Resident #1's, face sheet dated 06/26/2025 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for care plans. Resident #1 did not have a care plan for Cognitive Loss/Dementia, Communication, Urinary Incontinence, Behavioral Symptoms, and Pressure Ulcers. Resident #1's care plan also did not include the physician's order for a wander guard or why the wander guard was ordered. Resident #1 did not have a care plan for her behaviors related to her diagnoses. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Record review of the face sheet, dated 05/05/2025, revealed Resident #1 was a [AGE] year-old female who admitted to the facility…

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 information to resident's and their representatives on their rights related to filing grievances or concerns for 9 of 15 confidential residents. The facility failed to ensure 9 of 15 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information in regard to who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and Record Review during Resident Council on, 04/08/2025 at 2:30pm, 9 of confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council…

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 comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 18 residents (Residents #23 and #36) reviewed for care plans in that: The facility failed to ensure that Resident #23's care plan was revised, updated, and individualized with interventions and goals to address Resident #23's vison. The facility failed to ensure that Resident #36's care plan was revised, updated, and individualized with interventions and goals to address Resident #36's vision, activities, and pressure ulcers. This failure could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address…

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.

Resident #29 Care Planning 04/09/25 02:41 PM record review shows discrepancies' with several of the care plan not being care planned. 04/10/25 12:26 PM It was determined that resident had several triggered MDS items that were not care planned. Resident #40 Care Planning 04/10/25 12:25 PM It was determined that resident had several triggered MDS items that were not care planned. Resident #145 Care Planning

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for palatability, attractiveness, and appetizing. The facility failed to ensure foods were at appropriate temperatures. The facility failed to ensure proper handwashing during preparation of foods. The facility failed to provide edible (unburnt) food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses. The findings included: The following observations were made on 04/09/25 at 11:05 AM during observation of lunch meal preparation: Kitchen staff member A was observed several times with handwashing throughout the cooking process and did not wash her hands for the stated 15 seconds with soap. There were several times throughout the observation process that kitchen staff member had just rinsed her hands with water and then dried her hands. Kitchen staff member A was observed at 11:21 AM, picking up…

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 6 of 10 residents (Residents #41, #32, #98, #38, #195, #40) reviewed for infection control. 1. MA A failed to sanitize the blood pressure cuff between resident use for Resident #41 and Resident #32. 2. MA A failed to sanitize the blood pressure cuff between resident use for Resident #32 and Resident #98. 3. MA A failed to sanitize the blood pressure cuff between resident use for Resident #98 and Resident #38. 4. CNA C failed to utilize hand hygiene between glove changes during incontinence care with Resident #195. 5. CNA B failed to change gloves and perform hand hygiene during incontinence care with Resident #40. These failures could place residents at risk for cross contamination and infection. The findings…

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 residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for Quality of Care. The facility failed to transfer Resident #1 to bed on 03/03/25 resulting in him staying up in his wheelchair until the following morning (03/04/25). These failures could place residents at risk of not receiving necessary care or appropriate transfer. Findings included: Record review of Resident #1's face sheet, dated 03/11/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include muscle weakness, sleep apnea (sleep disorder characterized by repeated pauses in breathing during sleep), hereditary and idiopathic neuropathy (underlying nerve damage), and major depressive disorder, Transient Ischemic Attack (temporary interruption of blood flow to the brain that causes stroke-like symptoms that resolve within 24 hours). 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 observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 Residents (Resident #1) reviewed for catheter care in that: The facility failed to ensure Resident #1 had physician orders for a urinary catheter. This failure had the potential to affect residents by placing them at an increased risk of not receiving the appropriate care or services related to the urinary catheter. Findings include: Record review of the admission record for Resident #1, dated 01/31/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: unspecified sequelae of cerebral infarction (long-term effects of a stroke in the brain), type 2 diabetes (blood sugar problems), essential hypertension (high blood pressure), and urinary tract infection (bladder infection). Record…

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 obervation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administration of drugs that meet the needs of all residents for 1 of 5 residents (Resident #1) reviewed for pharmacy services. ADON failed to make sure that drugs and biologicals are prepared and given by the same person by preparing a medication and giving it to CNA to administer to Resident #1, on 12/30/2024 around 10:30 AM per anonymous complaint dated 12/31/2024. This failure could place residents at risk for not receiving medications correctly. Findings included: Record Review of Resident #1's facesheet dated 01/08/2025 revealed that Resident #1 was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #1 had a medical history of acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), epilepsy (disorder in which nerves cell activity in the brain is disturbed,…

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 drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 5 residents (Resident #1) reviewed for pharmacy services. A. The facility failed to monitor, review, and reconcile Resident #1's medication administration record from April 2024- October 2024. This failure placed residents at risk for not receiving prescribed medications and drug diversion. Findings included: Record review of Resident #1's face sheet, dated 10/17/24, reflected a [AGE] year-old, who was admitted to the facility on [DATE]. He was diagnosed with Dementia (the loss of cognitive functioning), Alzheimer's disease (memory loss), and altered mental status. Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: *Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. *Section B0800.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #1 and #3) and 3 of 3 (LVN D, CNA G and CNA H) staff reviewed for infection control. LVN D failed to follow enhanced barrier precautions, change gloves, and wash her hands or use ABHR during Resident #1's and #3's wound care and Resident #3's transfer to bed. CNA G failed to follow enhanced barrier precautions before entering and exiting Resident #3's room. CNA H failed to follow enhanced barrier precautions before entering and exiting Resident #3's room and during the transfer of Resident #3 to bed. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #1 Record review of Resident #1's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of residents for one of five residents (Residents #2) reviewed for wound care. The facility failed to follow physician's orders for wound care for Residents #2. The failure placed residents at risk of wound deterioration and infection. Findings included: Record review of Resident #2's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2's diagnoses included ORIF Left hip (Surgical hip replacement), Epilepsy (seizure disorder), end stage renal disease (kidney disease), and major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Review of Resident #2's Quarterly…

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, observation, and record review the facility failed ensure residents with wounds receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing or spreading for 1 of 2 Residents (Resident #1). The facility failed to follow physician's orders for Resident #1's pressure ulcer. This failure placed Residents at risks for infection and the development of new or worsening pressure injuries or wounds. Resident #1 Record review of Resident #1's clinical record reflected a face sheet, dated 09/12/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included hypotension (low blood pressure), multiple sclerosis (chronic autoimmune disease), schizoaffective disorder (mental illness), bipolar disorder (mental illness that causes extreme mood swings, energy changes and difficulty concentrating), major depressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for 1 of 1 residents (Resident #3 reviewed for privacy issues in that: 1. CNA A failed to provide full privacy for Resident #3 during peri care by not completely closing privacy curtains or providing a towel or sheet during peri care. 2. ADON failed to provide privacy by not providing a sheet or towel to cover the resident and not fully drawing Resident #3's curtain during peri care and wound care. This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by. Findings include: Resident #3: Record Review of Resident #3 face sheet dated 07/07/2024 originally admitted on [DATE] with a readmission date of 06/27/2024 reveals a [AGE] year-old female with a diagnosis of: metabolic encephalopathy (chemical imbalance in the blood that causes a problem with the brain), urinary tract infection, hyperlipidemia (a condition in which there are high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 to help prevent the development and transmission of communicable diseases and infections for 3 of 4 Residents observed for infection control for practices (Resident #2, #3, #4) in that: 1. CNA A failed to wash her hands before or during providing incontinent care for Resident #2. CNA A failed to wash her hands for the 15 seconds per facility policy. 2. CNA A failed to wash her hands before, during, and after providing incontinent care for Resident #3. 3. CNA A and CNA B failed to wash their hands before, during, and after providing incontinent care for Resident #4. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Resident #2: Record Review of Resident #2's face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary…

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 highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to implement a care plan area for physician order for pressure ulcer treatment of coccyx (the small bone at the bottom of the spine), left thigh, coccyx, and left hip. The facility did not have a care plan area for Resident #1 removing his own dressing from his pressure ulcers. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Record review of Resident #1 face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnoses of lung cancer, anemia, low potassium, high blood pressure, hyperlipidemia, atherosclerotic heart disease, nicotine dependence, cancer in bone, tachycardia, congestive heart failure, acid reflux. 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 observations, interviews and record reviews, the facility failed to ensure Resident 1's Physician Ordered dressings for the left thigh, coccyx, and left hip, based on the comprehensive assessment of a resident the resident 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 (Residents #1) resident reviewed for pressure ulcer care, in that: 1. Resident #1's pressure ulcer on his left thigh was observed being uncovered with no dressings. Resident #1's pressure ulcer on coccyx (a small bone at the base of the spinal column) was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcers being exposed. Resident #1's pressure ulcer to the coccyx was observed with the dressing soaked with drainage from the pressure ulcer. These failures could place residents with wounds at an increased and unnecessary risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure pots, pans and mixing bowls were stored in a manner to prevent contamination. 2. The facility failed to ensure foods were covered when being served out of the dining room. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observation during initial tour of the kitchen on 02/27/24 at 09:30 AM revealed pots and pans stored upright under the metal prep table. Mixing bowls were stacked inside each other stored right side up under the metal prep table. Observation during meal service on 02/27/24 at 12:10 PM revealed hall trays being prepared. DS A placed a fruit bowl on each tray which was uncovered. During observation of the kitchen on 02/28/24 at 09:45 AM revealed pots and pans stored upright…

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 have physician orders for the resident's immediate care, at the time each resident was admitted for 1 of 3 residents (Resident #23) reviewed for admission Physician Orders. The facility failed to have Physician orders for dialysis treatments, graft dressing, changes and resident care before and after dialysis for Resident #23. This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health. Findings include: Record review of Resident #23's face sheet dated 02/27/24 revealed an admission date of 01/03/24 with diagnoses which included: chronic systolic congestive heart failure (heart disease), end stage renal disease (kidney disease), and dependence on renal dialysis (kidney treatments). Record review of the facility's document titled, Resident Matrix, dated 02/27/24 revealed Resident #23 received hemodialysis treatments. Record review of Resident #23's comprehensive…

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 new residents were not admitted with mental disorders unless the State mental health authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the state mental health authority, prior to admission for 3 of 19 residents (Residents #11, #28 and #43) reviewed for PASARR screenings. The facility failed to ensure Residents #11, #28 and #43 had an accurate PASARR Level 1 assessment when they had a diagnosis of mental illness. This failure could place residents at risk for not receiving care and services to meet their needs. The findings were: 1. Record review of Resident #11's face sheet, dated 02/07/24, reflected a [AGE] year-old female with an initial admission date of 01/10/23 and readmission on [DATE]. Resident #11 had primary admitting diagnoses which included metabolic encephalopathy (alteration in consciousness caused due to brain dysfunction) dated 10/25/23 and additional…

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 for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Residents #9, #11 and #160) reviewed for care plans. This facility failed to develop a care plan for Residents #9, #11 and #160 to include bedrails. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #9 Record review of the admission record for Resident #9, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). Record…

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 residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #23) reviewed for dialysis. The facility failed to ensure Resident #23 had physician's orders for dialysis treatments, graft dressing changes related to dialysis or resident care before and after dialysis. This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health. The findings were: Record review of Resident #23's face sheet dated 02/27/24 revealed an admission date of 01/03/24 with diagnoses which included: chronic systolic congestive heart failure (heart disease), end stage renal disease (kidney disease), and dependence on renal dialysis (kidney treatments). Record review of the facility's document titled, Resident Matrix,…

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 review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 of 19 residents (Resident #9, # 11 and #160) reviewed for bed rails. The facility failed to obtain consent prior to installing and utilizing bedrails for Residents #9, #11 and #160. This failure could place residents at risk for potential injuries. Findings include: 1. Record review of the admission record for Resident #9, dated 02/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses which included: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). Record review of the comprehensive MDS assessment, dated 01/11/24, reflected Resident #9 was understood and had a BIMS score of 00, which indicated the resident's cognition was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 2 of 5 (Resident #1 and Resident #2) reviewed for neglect. The ADM and DON failed to report Resident #1 fall that resulted in the resident sustaining 2 head laceration and being transported to a local emergency room. The ADM and DON failed to report Resident #2 fall that resulted in a Compression fracture of lumbar vertebra . These failures could place residents at risk of allegations not being reported and residents being at risk for emotional and physical abuse 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 have evidence that all alleged violations were thoroughly investigated for 2 of 5 allegations reviewed for reporting alleged resident abuse (Resident #1 and Resident #2). The facility failed to ensure an allegation of neglect for Resident #1 was thoroughly investigated. The facility failed to ensure an allegation of neglect for Resident #2 was thoroughly investigated. these failures could place residents at risk of unidentified abuse due to allegations not being investigated as required. Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling). Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 1 of 5 residents (Resident #1) reviewed for misappropriation of property and exploitation. The facility failed to prevent the misappropriation of Resident #1's money and debit card, when CNA A allowed Resident #1 to purchase a meal for her in the amount of $27.03 using Resident #1's debit card number. Shortly after the purchase of the meal approximately 23 transactions were attempted to transfer money from Resident #1's account to Cash App. Seven of the attempted transactions were to CNA A's name. This failure could place residents at an increased risk for misappropriation of their property. Findings include: Record review of Resident #1's undated faces sheet indicated the resident was admitted to the facility on [DATE]: Her diagnosis include depression, acute kidney failure, diabetes mellitus, and heart failure. Record review of Resident…

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