Baybrooke Village Care and Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #28) of 4 residents reviewed for ADLs. The facility failed to ensure Resident #28's fingernails were kept clean.This failure had the potential to affect residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life. Findings included:Record review of Resident #28's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. Record review of Resident #28's care plan dated 02/10/26 reflected the resident required assistance with personal hygiene related to weakness. Interventions included providing extensive assistance with personal hygiene. During an observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 6 residents (Resident #50) reviewed for range of motion. The facility failed to ensure Resident #50 had her hand splint applied to her left hand per physician orders for contracture management. The failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included:Record review of Resident #50's quarterly MDS Assessment, dated 02/06/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included Diabetes Mellitus (high blood sugar resulting from the body's inability to properly use insulin), Hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following nontraumatic intracerebral hemorrhage…

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, based on a resident's comprehensive assessment, maintained 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 the resident preferences indicated otherwise for of 1 of 6 residents (Resident #53) reviewed for nutrition. The facility failed to monitor Resident #53's weight when she gained 16 pounds in 20 days, while receiving all her nutrition via a feeding tube. This failure could place the residents at risk of weight loss/gain, and a decline in their physical condition. Findings included:Record review of Resident #53's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included diabetes, stroke (when blood flow to part of the brain is blocked or a blood vessel bursts, depriving brain tissue of oxygen) aphasia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 3 residents (Resident #9) reviewed for enteral feeding. 1. The facility failed to ensure RN G mixed each crushed medication with water and administered one medication at a time through Resident #9's g-tube.2. The facility failed to ensure RN G administered Resident #9's g-tube medication by gravity. These failures could place residents at increased risk of aspiration, bloating discomfort, and not receiving the full benefit of the medications administered.Findings included:Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female admitted [DATE] with diagnoses that included aphasia (language disorder resulting from damage to the brain), paraplegia (paralysis affecting the lower half of the body), malnutrition (when the body does not get enough nutrients), 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 that respiratory care was provided consistent with professional standards of practice for 1 (Resident #56) of 6 residents reviewed for respiratory care, in that: The facility failed to obtain a physician order for Resident #56's use of supplemental oxygen.This deficient practice could affect residents who received oxygen therapy continuously placed residents at-risk for respiratory infection, and ineffective treatment.Findings included:Record review of Resident #56's quarterly MDS Assessment, dated 02/09/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #56 had diagnoses which included Type 2 diabetes mellitus without complications (high blood sugar resulting from the body's inability to properly use insulin), Non-Alzheimer's Dementia (problems with memory and thinking), heart failure, hypertension (high blood pressure) and cancer. Resident #56's BIMS score was 09, which indicated moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 of 1 resident (Resident #58) reviewed for dialysis.The facility failed to ensure post-dialysis assessments were completed for Resident #58. This failure could place residents at risk of inadequate post-dialysis care.Findings included:Record review of Resident #58's admission MDS Assessment, dated 01/01/26, reflected a [AGE] year-old male admitted [DATE]. Resident #58 had diagnoses which End-Stage Renal Disease, hypertension, heart failure, Diabetes Mellitus and hyperlipidemia. Resident #58's BIMS score was 15, which indicated his cognition was intact. The MDS Section O - Special Treatments, Procedures, and Programs reflected the resident received dialysis. Record review of Resident #58's care plan dated 03/19/26 reflected the following: Problem/Strengths: Dialysis. Goal: Improve or maintain current kidney function.…

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 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 2 of 4 medication carts (Hall 100 and 200 carts) reviewed for pharmacy services. The facility failed to ensure two boxes of fast acting 40% glucose gel, with an expiration date of April 2025, had been removed from the Hall 100 and 200 medication carts. This failure could place residents at risk of receiving medications that were ineffective. Findings included: Observation on 04/08/26 at 10:14 a.m., of the 100-hall medication cart with RN F revealed 1 unopened box of Fast Acting 40% Glucose Gel (concentrated, rapid absorption treatment for low blood sugar) with an expiration date of 04/2025. Observation on 04/08/26 at 10:26 a.m., of the 200-hall medication cart with RN G revealed 1 unopened box of Fast Acting 40% Glucose Gel, with an expiration date of 04/2025. Interview on 04/08/26 at 10:22 a.m., with RN F…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #1 and Resident#2) of 4 residents reviewed for quality of care.1. The facility failed to ensure Residents #1 was being provided with oxygen on 03/05/26 at 02:02PM as per physician's orders. 2.The facility failed to ensure Resident #2 had physician's order in her chart for oxygen that was observed being provided on 03/05/26. This failure could place residents at risk of illness and respiratory complications.Findings included:1.Record review of Resident #1's entry MDS Assessment, dated 02/02/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 4, and his diagnoses included Shortness of breath, and he was on continuous oxygen therapy.Record review of Resident #1's care plan dated 01/31/2026 reflected: Problem…

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 records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Residents #1) of 1 resident reviewed for quality of care.The facility failed to ensure Resident #1's Stage 4 pressure ulcer on his sacrum was covered with a dressing on 03/05/26.This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents.Findings included:1.Record review of Resident #1's entry MDS Assessment, dated 02/02/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 4, and his diagnoses included diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (hyperglycemia) due to insufficient insulin production (Type 1) or ineffective insulin 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to inform the resident's physician, responsible party, and notify, consistent with his or her authority, when there was a change in condition for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician when a change in blood pressure was discovered for Resident #1. The physician was not made aware of the continuous low blood pressure vital checks until Resident #1 was being evaluated to be transferred to the hospital for an unrelated treatment. This deficient practice could place residents at risk of not having their physicians informed when there was a change in condition resulting in a delay in medical intervention and decline in health.Findings included: Record review of Resident #1's Care Plan, dated 12/01/25, revealed a [AGE] year-old male. He was admitted to the facility on [DATE]. Diagnoses of hypertension (high blood pressure), Arteriovenous fistula (abnormal connection…

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 are free from significant medication errors for one (Resident #1) of 5 residents reviewed for significant medication errors. The facility failed to ensure Resident #1 received his prescribed seizure medication between [DATE] and [DATE]. This failure placed Resident #1 at risk for adverse effects, injury, and decrease in quality of life. Findings included: Record review of Resident #1's Face Sheet dated [DATE] 10:00 am revealed he was an [AGE] year-old male re-admitted to the facility on [DATE]. Relevant diagnoses included: encephalopathy (brain dysfunction) and epilepsy (abnormal signaling of nerve activity in the brain leading to seizures). Record review of Resident #1's MDS dated [DATE] revealed he was severely cognitively impaired with a BIMS score of 05. He utilized a walker and/or a wheelchair for mobility. He required supervision and/or set-up assistance from facility staff for cares. Record review of Resident #1's Physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure facility staff consulted with resident physician in a timely manner when there was a change in resident's physical, mental, or psychosocial status one (Resident #1) of four residents reviewed for physician notifications. The facility failed to notify Resident #1's physician that he was not provided his medication for epilepsy at any point between [DATE] - [DATE]. This failure placed Resident #1 at risk for adverse effects, injury, and decrease in quality of life. Findings included: Record review of Resident #1's Face Sheet dated [DATE] 10:00 am revealed he was an [AGE] year-old male re-admitted to the facility on [DATE]. Relevant diagnoses included: encephalopathy (brain dysfunction) and epilepsy (abnormal signaling of nerve activity in the brain leading to seizures). Record review of Resident #1's MDS assessment dated [DATE] revealed his cognition was impaired with a BIMS score of 05. He utilized a walker and/or a wheelchair for mobility. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received adequate supervision and assistance devices to prevent elopement for one (Resident #1) of six residents reviewed for elopements. The facility failed to ensure Resident #1 remained at the facility where he eloped [DATE] between 11:30 PM and 12:00 AM. Resident #1 was located approximately 0.1 miles away from the facility and returned to the facility by LVN F approximately 12:30 AM on [DATE]. This failure could place residents at risk of injury and a decreased quality of life.Based on record review and interview, the facility failed to ensure residents received adequate supervision and assistance devices to prevent elopement for one (Resident #1) of six residents reviewed for elopements. The facility failed to ensure Resident #1 remained at the facility where he eloped [DATE] between 11:30 PM and 12:00 AM. Resident #1 was located approximately 0.1 miles away from the facility and returned to the facility by LVN F 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 ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of two residents reviewed for Respiratory Care. The facility failed to ensure Resident #1's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 04/23/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #1's Face Sheet, dated 04/23/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with cough and anemia (low red blood cell). Record review of Resident #1's Quarterly MDS Assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 one (Resident #2) of 2 residents reviewed for Infection Control. The facility failed to ensure CNA B performed hand hygiene and changed her gloves while providing incontinent care to Resident #2 on 04/23/2025. This failure could place residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #2's Face Sheet, dated 04/23/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection. Record review of Resident #2 Quarterly MDS Assessment, dated 01/23/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated the resident 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 ensure each resident received food that accommodated their preferences for 3 (Resident #40, Confidential #1 and #2) of 8 residents reviewed for dietary services . 1. The facility failed to honor Resident #40's preferences and recommendations as indicated on his menu . 2. The facility failed to honor the preferences of Confidential Resident #1 as indicated on their menu selections. 3. The facility failed to honor Confidential Resident #2's wishes and continued to send the wrong food items on their tray. This failure could place residents at risk for not having their choices and food preferences accommodated, possible weight loss and a diminished quality of life. Findings included: 1. Record review of Resident #40's Face Sheet dated 1/29/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #40's Annual MDS assessment dated [DATE] reflected he had a BIMS score of 13 indicatedhe 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas. 3. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on 01/28/2025 at 9:15 AM, revealed the following: Dry storage area *One open clear container with 4 bags of vanilla wafers with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to 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 four (Resident #39, Resident #40, Resident #34, and Resident #52) of nine residents observed for infection control. 1. ADON A failed to perform hand hygiene between cleaning Resident #39's wounds and applying the clean dressings. 2. ADON A failed to perform hand hygiene and change her gloves when moving between wound sites during wound care for Resident #40. 3. CNA B failed to implement enhanced barrier precautions and don a gown while providing incontinent care to Resident #34. 4. CNA C and CNA D failed to implement enhanced barrier precautions and don a gown while transferring and providing incontinent care to Resident #52. These failures placed residents at risk for healthcare associated cross contamination…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #38) reviewed for quality of care The facility failed to ensure LVN F and CNA J used a gait belt when transferring Resident #38 from her wheelchair to bed on 01/28/25. These failures could place residents at risk for discomfort, pain, falls, injuries, and skin tears. Findings included: Record review of Resident #38's quarterly MDS assessment, dated 01/14/25 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #38 was severe cognitively impaired with a BIMs of 06. He had limited range of motion of both lower extremities, required total assistance with transfer from chair to bed/bed to chair. stroke, non-traumatic brain dysfunction, progressive Neurological Conditions, neurological Conditions, amputation, hip and knee replacement and fractures and multiple traumas. Review of Resident #38's 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 observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two residents (Resident #39) reviewed for feeding tubes. 1. The facility failed to ensure LVN F flushed Resident #39's feeding tube by gravity and not by pushing water by the plunger during medication administration. 2. The facility failed to ensure LVN F checked Resident #39's feeding tube placement and residual when starting a feeding. These failures could affect residents by placing them at risk of abdominal discomfort and obstruction of the G-tube. Findings included: Review of Resident #39's face sheet dated 01/29/25 revealed, the resident was a 69- year old female, admitted to the facility on [DATE]. Her diagnoses include chronic obstructive pulmonary disease, type 2 diabetes, anemia, and stage 4 pressure ulcer to the sacrum. Review of Resident #39's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 04 indicating severe…

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 a medication error rate below 5%, for 39 medication administration opportunities with 6 errors resulting in a 15% medication error rate, for 3 of 6 residents (Residents #66, #42, & #00) reviewed for medication administration. 1. RN G failed to administerAcetaminophen 500 mg per physician order, medication was administered at 09:30 and the medication was scheduled at to be administered at 12 pm. 2. RN G failed to administer Resident #42 Olmesartan during medication administration that was scheduled at 8 am. 3. RN G failed to administer Resident #00 medication per physician orders, medications scheduled at 8 am was administered at 11:15 am This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #66's admission record dated 1/30/2025 revealed an admission date of 08/26/22 with 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 observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (Resident #2, Resident #3, Resident #4, Resident #5, Resident # 6, and Resident #7) of eighteen residents observed for Infection Control. 1. The facility failed to ensure RN B performed hand hygiene during Resident #2 and Resident #3's wound care. 2. The facility failed to ensure MA E sanitized the blood pressure cuff between use for Resident #4, Resident #5, and Resident #6. 3. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinent care to Resident #7. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1.Review of Resident #2's Face Sheet, dated 09/11/2024, reflected the resident was a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored securely for one (Resident #1) of five residents reviewed for storage of medications. The facility failed to ensure a bottle of Nystatin topical powder was not left inside Resident #1's room. This failure could place the residents at risk of not receiving medications as ordered by the physician, accidental overdose, or misuse of medications. Findings included: Review of Resident #1's Face Sheet, dated 09/11/2024, reflected that resident was an [AGE] year-old male admitted on [DATE]. Resident #1 was diagnosed with gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach) without esophagitis( inflammation of the esophagus). Review of Resident #1's Comprehensive MDS Assessment, dated 08/23/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment also indicated Resident #1 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure Resident #1's nasal cannula was properly stored when not in use. The facility failed to ensure Resident #1's humidifier bottle had water in it. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #1's Face Sheet, dated 07/02/2024, reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included anxiety and chronic pain. Review of Resident #1's Quarterly MDS Assessment, dated 04/07/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment…

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

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 the facility's only kitchen. 1. The facility failed to ensure trash cans were covered and wiped down. 2. The facility failed to ensure 2 of 2 ovens were cleaned. 3. The facility failed to ensure the fryer was clean on the front and sides. 4. The facility failed to ensure the thickener container was sealed and the sugar plastic container wiped down, in the dry storage area. These failures place residents at risk for food-borne illness and food contamination. Findings include: 1. Observation on 12/05/23 at 9:48 AM revealed 3 of 4 kitchen trash cans, which had food debris, did not have full covered lids. There were food debris and particles on the trash can lid which had a 3-inch round hole in middle. One of four trash cans did not have a lid which had boxes and food debris in it between the food preparation area and dish area. One kitchen trash can lid had a crack on it from the hole to the side 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 observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Residents #52 and Resident #14) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths and grooming for Resident #52 and Resident #14. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth. Findings include: 1. Record review of Resident #52's Significant Change MDS assessment, dated 10/23/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMS of 8, which indicated he was moderately cognitively impaired. He had not rejected care and he indicated his daily preferences for choosing between a shower and sponge bath were very important to him. He was totally dependent for bathing…

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 assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for three of six residents (Residents #63, # 35 and #33) reviewed for pharmacy services. 1. LVN C failed to follow the manufacturer's instructions to [NAME] the Novolin R Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #63. 2. LVN C failed to follow the manufacturer's instructions to [NAME] the Admelog Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #35. 3. LVN D failed to follow the manufacturer's instructions to [NAME] the Humalog Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #33. These failures could place residents at risk of not receiving the full dosage of medication. Findings include: 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 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 three of eight residents (Residents #63, #35 and #33) reviewed for infection control. 1. LVN C failed to perform hand hygiene after performing FSBS on Resident # 63. 2. LVN C failed to perform hand hygiene after performing insulin injection on Resident #63. 3. LVN C failed to perform hand hygiene after cleaning the soiled glucometer and prior to administering Resident #35's pain medication. 4. LVN D failed to perform hand hygiene after cleaning the soiled glucometer and prior to drawing up Resident #33's insulin. Theses failure could place residents at risk for cross contamination and the development and transmission of communicable diseases and infections. Findings include: 1. Record review of Resident #63'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 the comprehensive care plans were prepared by an IDT that included the attending physician and a nurse aide with responsibility for the resident, and a member of food and nutrition services staff for one of 8 residents (Resident #54) reviewed for care plans. The facility failed to ensure the attending physician, a CNA, and dietary staff participated in the care plan conference for Resident #54. This failure could place residents at risk for not receiving adequate or individualized care. Findings include: Record review of Resident #54's admission MDS assessment, dated 11/29/23, reflected Resident #54 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included cellulitis of right upper limb, aphasia (language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) and seizure disorder . Resident #54 had a BIMS of 1, which indicated she was…

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

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of eight residents (Resident #35) reviewed for quality of care. The facility failed to ensure facility staff reported a wound on Resident #35's right upper arm which was first observed on 12/05/23 which in a delay of treatment until 12/06/23. This failure could place residents at risk of not receiving the care and treatment needed to their needs. Findings include: Record review of Resident #35's admission MDS assessment, dated 11/14/23, reflected a BIMS of 10, which indicated the resident was mildly cognitively impaired. Resident #35 required moderate assistance with toileting and upper body hygiene and was dependent on putting on/taking off footwear. Resident #35 was occasionally incontinent of bowel and bladder. Resident #35 had active diagnoses which included Diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of eight residents (Resident #10, Resident #12) reviewed for accident hazards and supervision. The facility failed to properly maintain wheelchairs for Residents #10 and #12. This failure could place residents at risk for discomfort, pain, and injuries. Findings include: 1.Record review of Resident #10's quarterly MDS assessment, dated 12/01/23, reflected an [AGE] year-old female with an admission date of 10/26/21. Resident #10 had a BIMS score of 9, which indicated she was mildly cognitively impaired. Resident #10 required moderate one-person assistance with transfers, and she had limited range of motion to both lower and upper extremities on one side. The resident was occasionally incontinent of urine and bowel. The resident's active diagnoses included cerebrovascular accident (stroke) Diabetes Mellitus. Record review of Resident #10'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.

Based on observations, interviews and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for areas in the facility (handrails) observed for a clean environment. The facility failed to ensure the handrails throughout the facility were cleaned daily, and in accordance with the facility's policy on Environmental Services. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas and does not present a Clean Homelike Environment. Findings include: Observations on 09/19/2023 at 10:45 AM of the facility high traffic areas, such as the handrails, revealed the handrails throughout the facility had dirt particles. The handrails with dirt stains and spills on the handrails. The inside layer of the handrails contained trash wedged in the corners, built up dirtparticles and dust, and a dead fly was observed. Interview with Housekeeping R on 09/19/23 at 10:50 AM revealed, the housekeeping staff are required to clean the high traffic areas at least once 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.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored according to guidelines. The facility failed to ensure the Ice Scooper Holder, located in the facility's only kitchen, was clean and sanitary. The facility failed to ensure the Iced Tea dispenser, prepared for residents, was covered, and sealed from air-borne diseases once prepared. The facility failed to ensure kitchen equipment was clean and sanitary. These failures could place residents at risk for cross contamination and other food-borne illnesses. Findings observed on 09/19/23 at 09:00 AM in the facility's only kitchen include the following: Ice Machine Scoop Holder had dirt particles on the outside and inside, with a lot of dirt particles dried up on the bottom of the Ice holder. The Ice Machine was had dirt…

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.