Focused Care at Midland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 of 5 (Resident #48) residents reviewed for smoking safety. The facility failed to ensure Resident #48's lighter, and cigarettes were not stored on their person. These failures could affect residents who smoke by putting them at risk of bodily harm or physical impairment. The findings included: Review of Resident #48's admission Record, dated 6/19/25, revealed he was a [AGE] year old male admitted to the facility on [DATE] with diagnoses including tobacco use. Review of Resident #48's Quarterly MDS, dated [DATE], revealed: He scored a 15 of 15 on his mental status exam (indicating he was cognitively intact). He needed set up or was independent with his ADLs. Review of Resident #48's Care Plan, last revised on 1/22/23 revealed: Resident #48 was an independent smoker, and he could go to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 8 residents (Resident #8) reviewed for medical records. The facility failed to ensure documentation was completed for Resident #8's emergency room visit on 05/28/2025. This deficient practice could place residents at risk of having inaccurate records due to incomplete documentation. Finding included: Record review of Resident #8's admission Record dated 06/19/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disease (lung disease that blocks airflow and causes difficulty breathing), and bipolar disorder. She was her own responsible party. Record review of Resident #8's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a mental…

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 notification of a resident's discharge to ensure that appropriate information is communicated to the Office of the State Long-Term Care Ombudsman for 1 or 6 residents (Resident #2 ) reviewed for transfer or discharge. The facility failed to ensure that: 1. Resident #2's discharge notification was sent to the Office of the State Long-Term Care Ombudsman. This deficient practice could affect resident's safe discharge planning by missed notification to the proper authorities. The findings included: Review of Resident #2's Order Summary Report active 1/09/24, undated, revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included high blood pressure, substance dependence in remission, bipolar disorder (mental illness shown by extreme and sudden mood swings) and diabetes. Review of Resident #2's Quarterly MDS Assessment, dated 12/24/24, revealed: Resident #2 had a mental status of 15 of 15 (indicating he 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 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 residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 2 residents (Resident #1) reviewed for supervision related care plans. 1. The facility failed to ensure a care plan was updated for Resident #1's elopements . These failures could place residents at risk for not receiving necessary care and services or having psychosocial care needs identified. Findings include: Review of Resident #1's admission Record, dated 4/29/25, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, brief psychotic disorder (had an episode of seeing things that were there or believing things that were completely irrational). Review of Resident #1 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 observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 Resident (#1) of 5 residents whose care was reviewed, in that: The facility failed to complete weekly skin assessments from 07/16/2024 to 09/23/2024 on Resident #1 at a minimum of every 7 days per facility policy. The facility failed to assess and provide treatment on 09/23/2024 when there were no orders for Edema on bilateral lower legs for Resident #1 observed with seeping serosanguinous fluid. This failure could place residents for not being provided with adequate care and treatment and place them at risk for skin breakdown, infection, pain, and a decline in health. The findings included: Record review of Resident's #1 admission Record dated 09/19/2024 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Resident #1's diagnoses 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.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable, environment for residents, staff, and the public for 6 of 6 hallways reviewed, including the dining room and kitchen for physical environment. The facility failed to ensure the floors were free of dirt and crumbs in the 6 hallways, dining room, and the kitchen on 09/19/2024 and 09/24/2024 that had dirt and food crumbs along the walls at the intersection between the floor and wall. This failure could the residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: In an observation of the facility on 09/19/2024 at 11:00 am, the floors in each of the 6 hallways had dirt and food crumbs along the walls at the baseboards. In the dining room, the floors were soiled and dirt and food crumbs along the walls at the baseboards. In an observation of the facility on 09/24/2024 at 11:20 am, the floors in each of the 6 hallways had dirt and food crumbs along the walls at the baseboards. In the dining room,…

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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for signing self in and out of the facility. The facility failed to ensure Resident #1 signed in and out of the facility when he left for pass. Resident #1 failed to sign out of the facility on 08/08/2024 and 08/17/2024. He failed to sign back into the facility after being out on pass on 08/02/2024, 08/05/2024, 08/11/2024, 08/20/2024, 08/30/2024, 09/01/2024, 09/04/2024, 09/06/2024, and 09/19/2024. This failure could place residents for not being provided with adequate care and treatment when signed out of the facility and evaluated when residents return to the facility. Findings included: Record review of Resident's #1 admission Record dated 09/19/2024 reflected a [AGE] year-old male, admitted to the facility on [DATE]. Resident #1's diagnoses included Paranoid Schizophrenia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #2) reviewed for infection control practices, in that: CNA A and Hospitality Aid B failed to perform proper hand hygiene after glove changes while providing incontinence care to Resident #2 on 09/19/2024. This failure could place residents at risk for the spread of infection. The findings included: Record review of Resident #2's admission Record, dated 09/09/2024, reflected a [AGE] year-old male, with the latest admission date of 07/08/2024. Diagnoses included cerebral infarction (stroke) and need for assistance with personal care. Record review of Resident #2's Comprehensive Care Plan, dated as last revised on 09/11/2024 reflected: Focus: I have an ADL self-care performance deficit related to stroke.…

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 and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 5 residents (Resident #2, #3, and 4) reviewed for care plans in that: The facility failed to ensure Resident #2 had a care plan in place to address EBP addressing his pressure ulcers or catheter. The facility failed to ensure Resident #3 had a care plan in place to address EBP addressing his catheter, feeding tube, or pressure ulcer. The facility failed to ensure Resident #4 had a care in place to address EBP addressing his catheter and pressure injury. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings include: RESIDENT #2 Review of Resident #2's admission Record, dated 8/29/24, revealed he was a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3, and #4) reviewed for Enhanced Barrier Protections (EBP) for infection control practices. The facility failed to ensure Residents #2, #3, and #4 were identified for and had implemented Enhanced Barrier Precautions. This failure could place resident's risk for cross contamination and the spread of infection. Finding included: RESIDENT #2 Review of Resident #2's admission Record, dated 8/29/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including stoke, chronic osteomyelitis (bone infection) of left ankle and foot), stage IV pressure ulcer of sacral region (tail bone), stage III pressure ulcer of right hip, and neuromuscular dysfunction of bladder…

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 (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #1 after returns from dialysis treatment. This deficient practice could affect residents who received dialysis treatments and placed them at risk for complications and not receiving adequate care and treatment to meet their needs. Findings included: Review of Resident #1's admission Record, dated 8/28/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including diabetes, stage 5 chronic kidney disease (end stage renal disease usually accompanied by dialysis). Resident #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 interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 10 (Residents # 33, #37, #72, #79 and #137) residents reviewed for comprehensive care plans. 1.The facility failed to ensure Resident #33 dated 01/20/24 had a care plan in place regarding his urinary catheter. 2.The facility failed to ensure Resident #37 had a care plan in place regarding her PEG (percutaneous endoscopic gastrostomy) tube. 3.The facility failed to ensure Resident #72 had a care plan in place regarding his urinary catheter. 4.The facility failed to ensure Resident #79 had a care plan in place for significant, unplanned weight loss. 5.The facility failed to ensure Resident #137 had a care plan in place for the use of psychotropic medication. These failures could place residents at risk…

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 each resident received adequate supervision and that the resident environment remained as free of accident hazards as possible for all of the residents in the facility's 3 secured units (Hall C, E and F ) reviewed for accidents and supervision. The facility failed to ensure the secure units exit doors at the end of each hall had alarms to indicate and alert staff that the residents were going outside to the secure unit patios on 04/09/24 through 04/11/24. This failure placed residents at risk of injury due to not being supervised and placed at risk of accidents/hazards. Findings included: During observations from 04/09/24 through 04/11/24 several residents were observed in the men's and women's secure units going in and out to the secure unit patios. Residents were seen sitting down in the chairs provided outside and then seen walking back inside. Staff were seen in the secure units monitoring the residents that were inside but not necessarily the residents that were out in the patios. During an…

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

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. The facility failed to: Provide a clean kitchen. Ensure food items in the freezer were labeled and dated. Ensure food items in dry pantry were sealed appropriately. This deficient practice could affect residents who receive meals prepared from the kitchen and served by facility staff at risk for food borne illness and cross contamination. Findings included: Observation and interviews on 04/09/24 between 9:00 a.m. and 10:30 a.m. findings revealed: Water was pooled in front of the three-compartment sink. Walk through of dry pantry showed 1-12-ounce bag of dry gravy, opened and spilling on floor. Brown grime up along the walls and under the storage shelves. Buildup of grime on equipment. Stainless steel freezer doors and handles, rolling carts, and kitchen floors were visibly dirty. The wall behind the dishwasher was covered in black grime. The freezer had 2 opened,…

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 maintain an effective pest control program so that the facility was free of pests and rodents for one of one facility reviewed. The facility failed to ensure the facility was free of rodents. This failure could place the residents at risk of unsanitary and unsafe conditions. Findings included: During a confidential group interview on 4/10/24 at 11:48 am with nine residents, it was stated that the facility changed to a new pest control company in February 2024. All nine residents agreed that the new company had done very well in getting rid of the bugs in the facility but there was still a problem with mice. All residents present for the meeting agreed that the facility continued to have a problem with mice and two of the residents stated that they each have a pet mouse that they have named in their room (they did not live in the same room) that would get on their beds and let them feed them from their hand and pet them. All residents present denied any injuries - bites, scratches - from any rodents in 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 the dignity right was respected for 2 of 20 residents (Resident#33 and Resident #72) reviewed for privacy and dignity. Resident #33 and Resident #72 had urinary catheter drainage bags that were not covered with privacy bags, and the urine content of the bag was visible to other residents, visitors, and facility employees. This failure placed residents at risk for violation of privacy. The findings included: Review of Resident #33's admission Record revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. The admission Record documented her diagnoses included congestive heart failure (heart fails to pump), type 2 diabetes (body's inability to control blood sugars), retention of urine, prostate hypertrophy (prostate gland enlargement which causes urinary difficulty). Record review of the quarterly MDS dated [DATE] for Resident #33 indicated BIMS was 05, required extensive assistance by two persons for bed…

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 ensure the accurate administering of all drugs to meet the needs of the residents, for 1 of 4 medication carts reviewed for pharmacy services, in that: . The medication cart used for halls A, B and C had two insulin pens dated (03/06/24) that had expired as indicated by the manufacturer's recommendations since they were only good for 28 days after being opened. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings included: During an interview and observation on 04/09/24 at 11:28 AM the medication cart for halls A, B and C was inspected with LVN A present. Inside the cart was 1 insulin pen with an open date of 3-6-24 and another one dated 3-6-24. Both pens indicated to dispose after 28 days according to manufacturer recommendations. The LVN said she had not noticed the pens had already expired or else she would have replaced them. During an interview on 04/09/24 at 11:32 AM…

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 all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for one medication carts (the medication cart for halls A, B and C) of four medication carts reviewed for drug storage. The facility failed to ensure medication carts were left unlocked and unsupervised on 04/09/24. These failures could place clients at risk for drug diversion or accidental ingestion. The findings included: During an observation on 04/09/24 at 11:24 AM the medication cart used for halls A, B and C was noted to be unlocked, unattended and unsupervised by staff. During an interview and observation on 04/09/24 at 11:28 AM LVN A said if the cart was left unlocked and unattended it could lead to unauthorized people having access to it or any residents getting into it. The LVN said she stepped away and forgot to lock it. The cart was inspected with LVN A present and several over the counter and prescription medications were located in the cart. During an interview on 04/09/24 at…

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 a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environment. The facility failed to ensure that wastewater was not discharged onto the ground outside the main entrance into the parking lot on 04/09/24 and 04/10/24. This failure could place the residents, staff, and the public in danger of contracting illness and disease from vector borne transmission of infectious bacteria and viruses. Findings included: Observations on 04/09/24, at 2:30 pm and again on 04/10/24, at 9:30 am revealed the main entrance parking lot had grey colored water streaming from a drain clean out located at the end of A Hall. There was pile of soiled toilet tissue next to the drain clean out. The stream of grey water ran from clean out location to end parking lot, pooling in areas next to exit on A hall. Observation on 04/10/24 at 8:30 am revealed the Maintenance Director outside the building at the end of A Hall with a shovel filling in a hole at 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 provide a safe, clean, comfortable, and homelike environment for 4 of 8 residents (Resident #1, Resident #4, Resident #6, and Resident #7) reviewed for homelike environment. The facility failed to provide needed housekeeping and maintenance for the dining room, hallways, for Resident #1, Resident #6, and Resident #7. The facility failed to keep sound levels comfortable for Resident #4 and Resident #7. These failures could place the residents at risk of increased anxiety, unsanitary conditions, and uncomfortable conditions. Findings included: Observation on 2/9/24 at 3:58pm revealed debris, white paper, white paint spots on the floor in hallways A, B, D, F, and dining room. Observation on 2/9/24 at 4:07pm revealed debris on the floor in the dining room, pink sugar packets and white substance near two different trash cans on the floor. There were debris and dirt located behind the dining room door and in corners of the dining room.…

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 maintain an effective pest control program so that the facility was free of pests and rodents for one of one facility reviewed. The facility failed to ensure the rooms of residents and the dining room tables were free of pests and rodents. This failure could place the residents at risk of unsanitary and uncomfortable conditions. Findings included: Observation on 2/9/24 at 4:20 pm revealed three roaches on the wall of the conference room. The ADM took her shoe off and smashed roaches to the wall. Interview on 2/9/24 at 4:20pm with the ADM revealed the facility were under QAPI for the roach problem and it was an ongoing issue. The ADM revealed this had been an issue as long as she had been at the facility, and she was hired in 2019. The ADM stated she had showers fixed, was updating the building one room at a time as she is able, and she had replaced some furniture. The ADM stated she had two pest control companies coming once a week but was only able to provide documentation for one pest control company…

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 for 1 of 1 kitchen reviewed in that: The facility failed to discard expired food items. The facility failed to maintain effective pest control in the kitchen. The facility's kitchen staff failed to practice proper hand hygiene. These deficient practices affected residents who received meals prepared from the kitchen and placed them at risk for food borne illness and cross-contamination. Findings include: Observation of the kitchen on 03/07/2023 at 9:45 a.m. during an inspection of the refrigerator revealed the following: 1 gallon size storage container of white pudding-like substance, not labeled, not dated. Observation of the kitchen on 03/07/2023 at 10:15 a.m. during an inspection of the pantry revealed the following: Four packages of yellow corn meal mix, 6 oz. boxes, with each box containing holes that appeared to be gnawed through the packaging. 5-pound bag of graham cracker crumbs, with holes 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 maintain an effective pest control program so that the facility was free of pests and rodents 1 of 1 Kitchen, 1 of 1 Dining Room, Secured Unit E, Secured Unit F, room [ROOM NUMBER] and room [ROOM NUMBER]: The facility failed to ensure an effective pest control program was in place to keep cockroaches out of Dining Room and resident rooms. The facility failed to ensure an effective pest control program was in place to keep mice out of kitchen pantry. These failures could place residents at risk of potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings include: Observation on 03/06/23 at 09:45 AM revealed two live cockroaches crawling on wall of Dining Room. Interview on 03/06/23 at 11:03 AM a resident stated his only complaint was he had a mouse in his room. The resident stated he told the nurses and they put a glue trap out for it for about a month but all that was caught was bugs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 5 of 9 residents (Residents #21, #28, #37, #135, #235) reviewed for resident rights . Resident #21 had no consent for the antipsychotic medication dextromorphan-quinidine. Resident #28 had no consent for the antianxiety medication buspirone, antidepressant medication duloxetine, the antipsychotic medication olanzapine, or the antidepressant medication trazodone. Resident #37 had no consent for the antidepressant medication Sertraline or the antianxiety medication Buspirone. Resident #135 had no consent for the antidepressant medication Duloxetine and the antidepressant…

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 and interview the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 12 of 29 (Residents #5, #16, #18, #21, #23, #24, #25, #32, #39, #44, #65, #68) resident rooms reviewed for call lights. Residents call lights were on the floor, behind furniture, or coiled on the wall unit, out of reach while residents were in their room. This deficient practice could affect residents who need assistance with activities of daily living of not having needs met. Findings Include: Observation made on 3/6/23 beginning at 10:51 a.m. revealed Resident #65's call light cord was on the floor out of reach of the resident. The resident sat on her bed. Observation on 03/06/23 at 3:15 PM revealed in Resident #9 there was no place to tie string to the switch (they would be unable to use call light). The resident was in her bathroom. The resident was capable of using the call light physically and mentally. Observation on 03/06/23 at 3:23 PM revealed in Resident #32 the call light was out of reach while the 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.

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 2 of 2 resident observed for mechanical transfers (Resident #38 and #68). CNA L and CNA M did not lock Resident #68's wheelchair prior to completing a mechanical lift transfer CNA N and CNA O did not lock Resident #38's wheelchair prior to transfer and did not correctly compete a two-person transfer. These failures could place residents who required two-person assistance during transfers at risk for injuries. Findings included: Review of Resident #68's admission Record dated 3/8/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cerebral palsy, muscle wasting and atrophy, muscle weakness, history of falls, and difficulty in walking. Review of Resident #68's Annual MDS assessment dated [DATE] revealed: She scored an 11 of 15 on her mental status exam (indicating she was moderately…

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 residents in 1 of 1 medication rooms reviewed for storage in that: 1. 6 boxes Acetaminophen Suppositories, containing 12 Rectal suppositories, 650 mg each with the expiration date of 01/2023. 2. One box of 10SG Urinalysis Reagent Strips, Quantity of 100, with the expiration date of 10/14/2022. 3. Two 5 oz (148 mL) bottles of Safe n Simple Ostomy Skin Barrier Powder Lot # 190312 with the expiration date of 03/12/2022. 4. One ready to use, with tubing attached (spiked ) IV bag on the countertop with no labeling. These failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Observations of 1 of 1 medication storage rooms on 03/07/2023 at 10:36 AM revealed the following medications were found to be expired: *6 boxes Acetaminophen Suppositories, containing 12…

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 all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 2 of 2 medication carts reviewed for storage in that: The facility failed to ensure that all medications were properly stored in 2 of 2 medication carts. This failure could result in a drug diversion. Findings included: Observation on 03/07/23 at 09:36 AM with MA-J of medication cart for #1 of 2, revealed and identified loose pills revealed as: 1. .5 trazadone 2. 1 thyroid med 3. 1 Topiramate 50 mg During observation on 03/07/2023 at 10:10 of MA-K, med cart # 1 loose pills revealed as: 1. 1 metopilol 2. 1 namenda 10 mg 3. 2 dextro amphetamine 4. 1 mirtrapine 5. 1 cyclobenzaprine 6. 1 lisionopril 20 mg 7. .5 amlodapine 8. 1 baclofen 9. 1 levothyroxine 10. 1 namenta 5 mg 11. 1 propanolol During an interview on 03/07/23 at 09:36 AM, the MA-J stated she tried to keep cart #1 clean at all times. During an interview 03/07/2023 at 10:20 AM the MA-K stated she cleaned cart #2 every day 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 observations, interviews and record reviews, the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct identified quality deficiencies for the memory care units on halls 2 of 2 halls whose environment was reviewed in that: The QAPI committee, which included the Administrator, DON, Medical Director, and the Clinical Reimbursement Director, did not identify quality deficient practices regarding Resident Room #'s 49, 50, 51, 53, 54, 56, 42, and 46 where the physical environment had not improved from past noncompliance. These deficient practices could affect the residents who were observed on the Memory Care Units, (Halls E/F). Findings Include: During observation on 03/06/2023 at 9:44 AM -10:45 AM Hall F revealed: Resident RM [ROOM NUMBER] A/B, there were missing floor tiles, broken blinds, cracked window seal, and drywall needed painting, a hole approximately 3x3 was in the closet door with no hanger in closet. 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.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of 1 kitchen reviewed for essential equipment. The facility's dishwasher was leaking and the kitchen floor drain was clogged causing 1 inch of contaminated water on floor from dishwasher and floor drain contaminants . This failure could place residents at risk of being exposed to slips and falls from 1 inch of standing water in kitchen and exposure to contaminated water and contaminated residual from dishwater overflow from drain. Findings include: Observations and interview of the facility's only kitchen on 03/06/23 09:45 a.m. and 11:45 a.m. revealed there was 1 inch of water pooled on the floor of the entire kitchen. Maintenance was vacuuming up the water with a shop vac. DM A stated the dishwasher leaked a lot and the Food Service Manager B attempted to fix it every time it leaked. Per the Food Service Manager B, the drain gets clogged and that caused the water to pool on the floor. Observation and interview…

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 and interview the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for each occupied resident room for 17 rooms (Rooms 1, 2, 6, 7, 12, 13, 14, 16, 17, 18, 20, 21, 23, 24, 26 here) of 48 rooms observed, in that: a). Semi-Private rooms did not provide full visual privacy (Rooms 1, 2, 6, 7, 12, 14, 17, 20, 21, 23 and 26). b). Rooms did not have curtains at all (rooms [ROOM NUMBER]). c). Rooms did not have blinds or curtains exposing the resident near the window (Rooms 16, 20, 23). These failure could affect residents by placing them at risk for loss of privacy and dignity. The findings include: Observation on 03/06/23 at 03:28 PM revealed room [ROOM NUMBER] A (Resident #9) had no curtain. Observation on 03/07/23 at 09:36 AM revealed the resident in room [ROOM NUMBER] (Resident #68) was transferred to the bedside commode. The aides helping the resident pulled the curtain in front of the door but when the resident in 6 B came in the aides were…

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 maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 37 of 48 rooms and 37 residents (#1, 5, 7, 8, 9, 11, 17, 18, 19, 21, 22, 23, 24, 25, 28, 32, 37, 38, 39, 40, 42, 44, 45, 47, 51, 52, 54, 55, 65, 66, 68, 70, 73, 75, 79, 235 & 236) reviewed for physical environment. Resident rooms and other areas accessible to the residents had drywall damage, missing baseboards, damaged ceilings and restrooms in need of repair or had furniture that was not in good repair or worn to the point of not being sanitizable. The main dining room's furniture was worn, in unsafe condition, and not-santizable. The lobby area's furniture was worn to threads. Hall A resident rooms had dry wall damage, missing baseboards, ceilings with water damage, restrooms in need of repair or had furniture that was not in good repair and/or were worn to the point of not being sanitizable. Hall B resident rooms had dry wall…

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 comprehensive assessments were completed within 14 calendar days after admission as required for 1 of 1 resident (Resident #235) reviewed for admission assessments. Resident #235 was admitted to the facility on [DATE] and did not have a completed admission/comprehensive MDS assessment within 14 days following admission to the facility. This failure could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings included: Review of Resident #235's Electronic admission Record dated 3/8/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included alcohol dependence with alcohol-induced persisting dementia, Wernicke's Encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1 that may result from alcohol abuse), major depressive disorder, psychotic disorder 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 interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents (Resident #28) reviewed for care plans in that: Resident #28 did not have a care plan in place to address her diagnoses of dementia, fibromyalgia, or pain management. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings include: Review of Resident #28's Electronic admission Record dated 3/8/23 revealed she was a [AGE] year-old female originally admitted to the facility 12/14/22 with a most recent admission date of 1/9/23. She had diagnoses which included Type 2 Diabetes Mellitus, dementia with behavioral disturbance, hyperlipidemia (high cholesterol), hypokalemia (low potassium), major depressive…

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.