Focused Care at Mount Pleasant

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure all food items were labeled and dated in Refrigerator #1.2. The facility ensure that wall in the pantry was in good repair. 3. The facility failed to ensure that the pantry was free of rotting food.4. The facility failed to ensure that a scoop for the sugar bin was properly stored. 5. The facility failed to ensure the ceiling under the air conditioner duct was in good repair.6. The facility failed to ensure that all air conditioner vents were clean and free of condensation. These failures could place residents at risk of foodborne illness and food contamination.Findings include: During an observation on 06/30/25 at 8:41 a.m., revealed one plastic bag containing one light brown round food item with no date or label in Refrigerator #1. During an observation 06/30/25 at 8:44 a.m., revealed a wall in the pantry with an air conditioner in the 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.

Based on observation and interview the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition.The facility failed to ensure Freezer #2 maintained a safe storage temperature and not allow food items to thaw.This failure poses a risk of essential kitchen equipment malfunctions causing foods to be held at an unsafe temperature and cause food borne illness. Findings included: Record review of a Kitchen Freezer Log for June 2025 revealed on 06/27/25 the morning temperature for Freezer #1 was 5 degrees. The temperature was initialed by [NAME] G. The evening temperature for 06/27/25 was 2 degrees Fahrenheit. On 06/28/25, the morning temperature was 0 degrees Fahrenheit, and the evening temperature was 3 degrees Fahrenheit. The morning temperature was initialed by the Dietary Manager. On 06/29/25, the morning temperature was 2 degrees Fahrenheit, and the evening temperature was 0 degrees Fahrenheit. The morning temperature was initialed by the Dietary Manager. On 06/30/25, the morning…

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 and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 5 of 17 residents (Resident #3, Resident #24, Resident #39, Resident #48, and Resident #119) and 4 anonymous residents reviewed for palatable food. 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents did not receive cold food. 3. The facility failed to ensure residents received preferred portion sizes. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: 1. Record review of a face sheet dated 07/01/25 revealed Resident #3 was a [AGE] year-old female and was admitted to the facility on [DATE] with diagnoses including congestive heart failure, muscle weakness, and anxiety. Record review of a quarterly MDS assessment dated [DATE] revealed 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 provide a safe, clean, and comfortable homelike environment for 2 of 20 resident's (Resident #7 and Resident #37) reviewed for a homelike environment.1. The facility failed to ensure Resident #7's wall was free from peeling paint at the head of her bed with approximately 4 different areas measuring approximately 1-2 inches wide and 2-3 inches long.2. The facility failed to ensure Resident #7's wall was free from peeling paint by her pillow that measured approximately 6-8 inches at the widest point and a foot long at the longest point.3. The facility failed to ensure Resident #7's air condition/heat unit was free from peeling paint and/or caulk around the unit leaving approximately half inch gaps around the top of the unit.4. The facility failed to ensure Resident #37's wall was free from peeling paint at the midway area of his bed that measured approximately 10 inches at the widest point and a foot long at the longest point.These failures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 9 residents reviewed for respiratory care. (Resident #7 and Resident #26)1. The facility failed to ensure Resident #7's oxygen concentrator (takes air from the surroundings, extracts oxygen and filters it into purified oxygen for resident to breathe) air intake area (mouth of the oxygen concentrator bringing in the air that will be processed) was not covered in gray fuzzy dust-like and hair-like particles.2. The facility failed to ensure Resident #7 had an order and care plan for oxygen therapy.3. The facility failed to ensure Resident #26's oxygen concentrator air intake area was not covered in gray fuzzy dust-like and hair-like particles.These failures could place residents at risk of respiratory complications or respiratory infection. Findings included:1. Record review of Resident #7's face sheet dated 6/30/25 indicated she was [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 observation, interview and record review the facility failed to ensure nurse aides were able to demonstrate competency in skills and necessary techniques to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 2 RCPs (RCP E) reviewed for nurse aide competencies. The facility failed to ensure RCP E was competent in performing a safe mechanical lift (machine used to lift and transfer a resident from one surface to another, such as from chair to bed/bed to chair) transfer on Resident #2 when RCP E did not place the legs of the mechanical lift in the wide position when lowering or transferring the resident and did not lock the lift wheels while lifting or lowering the resident.This failure could place residents at an increased and unnecessary risk of injury.Findings included:Record review of Resident #2's face sheet dated 7/02/25 indicated she was [AGE] years old and admitted to the facility on [DATE] and re-admitted [DATE]. Resident #2 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, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for enhanced barrier precautions (Resident #121) infection control practices.The facility failed to ensure RN C donned (put on) a gown prior administering medications and feeding to Resident #121 via g-tube. Resident #121 was on enhanced barrier precautions.These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings included: Record review of Resident #121's face sheet dated 07/07/25, indicated she was a [AGE] year-old female that admitted [DATE] with diagnoses that included: epilepsy (a disorder in which nerve cell activity in the brain disturbed, causing seizures), gastrostomy status (opening allows for a tube to be…

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 follow their own established smoking policy for 1 of 9 residents reviewed for smoking. (Resident #37)The facility failed to ensure Resident #37 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) at his bedside. This failure could place residents at risk for injury or harm. Findings included:Record review of Resident #37's face sheet dated 6/30/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #37 had diagnoses which included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), senile degeneration of the brain (decline in cognitive function associated with aging), lack of coordination, and nicotine dependence.Record review of Resident #37's annual MDS assessment dated [DATE], indicated he had a BIMS score of 9, which indicated he had moderate cognitive impairment. The MDS indicated Resident #37 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 , interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 2 residents (Resident #12) reviewed for drug diversion. The facility failed to prevent the drug diversion of 55 tablets of Hydrocodone (Norco) (a combination medicine that is commonly taken for severe pain) for Resident #12 on 2/6/2025. This failure could place residents at risk for drug diversion of physician ordered medications which could result in residents not having medications/treatments available and a decline in health. Findings include: Record review of Resident #12's face sheet, dated 4/17/2025, indicated a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #12 had diagnoses which included Alzheimer's disease (a progressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure residents were free from abuse for 5 of 66 residents (Resident #1, #2, #3, #4, and #5) reviewed for resident abuse. The facility did not ensure Resident (Resident #1, #2, #3, #4, and #5) were free from abuse. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1. Record Review of Resident #1's face sheet dated 2/11/25 at 2:15 p.m., indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), Delusional disorders (a psychotic disorder that can make it hard for a person to distinguish between what's real and what's imagined to be true), essential hypertension (high blood pressure).…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 8 (Resident #1) residents reviewed for abuse. The facility failed to protect Resident #1 from verbal and physical abuse from LVN A on 9/26/24 resulting in Resident #1 being pushed by LVN A and falling to the floor. The noncompliance was identified as PNC. The noncompliance began on 9/26/24 and ended on 9/27/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 12/19/24 indicated Resident #1 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including Alzheimer's, PTSD, difficulty walking, violent behavior, lack of coordination, and cognitive communication deficit (communication difficulty caused by cognitive impairment). Record review of the MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review of the face sheet, dated 05/24/2024, revealed Resident #30 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of anxiety disorder (mental illnesses that cause constant fear and worry) and neuropathy (numbness or tingling in hands or feet from damaged nerves). Record review of the comprehensive MDS assessment, dated 03/11/2024, revealed Resident #30 had clear speech and was understood by staff. The MDS revealed Resident #30 was able to understand others. The MDS revealed Resident #30 had a BIMS score of 7, which indicated severely impaired cognition. The MDS revealed Resident #30 was taking an antipsychotic and antianxiety medication during the last 7 days of the look-back period. Record review of the comprehensive care plan, initiated on 03/15/2024, revealed Resident #30 was taking an antipsychotic medication related to history of aggression, delusion, and agitation. Record review of the physician orders for Resident #30 revealed the following: o Risperidone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 4 of 20 residents (Residents #'s 13, 39, 44, and 59), reviewed for care plans. 1)The facility failed to revise and update Resident #13's comprehensive care to reflect his election of hospice services on 5/17/2024. 2)The facility failed to revise and update Resident #39's comprehensive care plan to reflect he was no longer residing on the secured unit as of 5/17/2024. 3)The facility failed to revise and update Resident #44's comprehensive care plan to reflect he was using oxygen continuously. 4)The facility failed to revise and update Resident #59's comprehensive care plan to reflect he was no longer receiving antibiotic and had an PICC (Peripheral Inserted Central Catheter) line since March 2024. These deficient practices could affect residents by placing them at risk of not receiving appropriate…

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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 73.08 %, based on 19 errors out of 26 opportunities, which involved 3 of 3 residents (Residents #14, #24 and #56) reviewed for medication administration. The facility failed to ensure Residents #14 and #24 medications were administered during the scheduled time. The facility did not ensure Resident #56 was given Famotidine 20 mg. The facility did not ensure Resident #56 Diclofenac Sodium 1% was applied to one extremity instead of both extremities. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #14's face sheet, dated 05/22/2024, indicated Resident #14 was a [AGE] year-old-male, originally admitted to the facility on [DATE] with a diagnosis 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.

Based on observation, interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 out of 1 kitchen reviewed for sufficient support personnel. The facility did not ensure the lunch meal on 05/20/2024, 05/21/2024, and 05/22/2024 were served on time. This failure could place residents at risks who consume food prepared in the kitchen at risk of foodborne illness. Findings included: Record review of the Meal Time Serving Order, sheet undated, indicated breakfast was started at 7:00 a.m. and lunch was started at 12:00 p.m. for the secured men's unit, dining room, women's unit and north hall. During an interview on 05/20/2024 beginning at 9:00 a.m., the Dietary Manager stated breakfast was served at 7:00 a.m. and lunch was served at 12:00 p.m. During an observation on 05/20/2024 at 12:30 p.m., first trays were wheeled to the secured men's unit. The first dining room trays were served at 12:50 p.m. The last trays on north hall were served at 1:45 p.m. During an observation…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated. 2. The juice machine spigot was free from a red gooey substance where the juice was dispersed. 3. Muffin pans were free from encrusted black colored grease buildup coating the entire outside and most of the inside surface. 4. The steam pans were stacked with water pooled in between them. 5. The microwave was clean and free of food debris. 6. The stove was clean and free of food debris. 7. Test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired. 8. Hair restraints worn. These failures could place residents at risk for foodborne illness. Findings included: During the initial tour observation with the Dietary Manager on 05/20/2024 between 9:00 a.m. and 9:45 a.m., the following was revealed: 1. 3 Muffin pans were free from encrusted black colored grease buildup coating…

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 2. Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), and obstructive and reflux uropathy (blocked or backward flow of uine). Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. The MDS in section GG-Functional Abilities and Goals indicated Resident #44 was dependent of the staff to complete all of the effort of toileting. The MDS in section H-Bladder and Bowel H0100Resident #44 was indicated to have an indwelling catheter and in H0300 to have not rated due to the use of a Foley catheter. Record review of the Comprehensive Care Plan dated 3/06/2023 indicated Resident #44 an indwelling catheter 18 French with a 10 cubic centimeter bulb and was at risk for increased urinary tract…

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 establish a infection prevention and control program that includes antibiotic use protocol and a system to monitor antibiotic use for 1 of 4 residents and reviewed for antibiotic stewardship program. (Resident #11) The facility did not ensure Resident #11 was assessed using the established and accepted criteria to determine if her UTI met the criteria for antibiotic use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: Record review of the face sheet, dated 05/24/2024, revealed Resident #11 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of schizophrenia (serious mental disorder that affects how people interpret reality), multiple sclerosis (disease that affects the brain and spinal cord and causes nerve damage and communication problems), and parkinsonism (umbrella term…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility is free of pests and rodents for 1 of 3 units (the facility's main building to include the dining room, hallway, and room [ROOM NUMBER], 49, and 52). The facility did not maintain an effective pest control program to ensure the facility was free of flies in the main building dining room, hallway, and Resident Room's 48, 49, and 52. These findings could place residents at risk for an unsanitary environment and a decreased quality of life. The findings included: Record review of the pest control log dated 10/10/2022, 03/02/2023, 06/07/2023, 09/06/2023, 10/05/2023, 11/01/2023, 12/09/2023, 01/03/2024, 01/30/2024, 02/07/2024, and 03/05/2024 revealed the pest control company had serviced the facility on the above dates . The log did not specify the areas that were serviced. Record review of the service notification from the pest control company , dated 05/01/2024, revealed Upon…

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 review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 3 dining room (women's secure unit dining room) reviewed for resident rights. The facility did not ensure LVN O treated residents with dignity and respect by referring to them as feeders in the women's secure unit during lunch meal service. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: During a dining observation on 05/22/24 at 1:15 p.m., LVN O was passing out dining trays to resident sitting at the dining table and loudly stated to the CNA the trays left on the dining cart were for the feeders in the women's secure unit. During an interview on 05/22/24 at 1:25 p.m., LVN O stated she was not going to lie, she did refer to the trays as belonging to the feeders. LVN O stated it was important not to use the word feeder because it was a dignity issue. LVN O stated using…

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 allow residents to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the family for 1 of 1 (Resident #44) resident reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #44 to his attorney within two working days of a request on 11/27/2023 for them. This failure could place residents at risk by causing a negative health impact due to not having continuity of care. Findings included: Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), diabetes, and stroke. Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 20 residents reviewed for advanced directives. (Resident #52) The facility failed to ensure Resident #52's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of the face sheet dated 05/22/2024, revealed Resident #52 was a [AGE] year-old male with a diagnose other frontotemporal neurocognitive disorder (an umbrella term for a group of brain disease that mainly affect the frontal and temporal lobes of the brain), cognitive communication deficit (difficulty with any aspect of communication that was affected by disruption of cognition), unspecified psychosis not due to a substance or known physiological condition (mental, behavioral and neurodevelopmental disorders). Record review of the MDS dated [DATE], revealed Resident #52 had a BIMS…

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 review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 2 locked units (men's secure unit dining room) observed for homelike environment. The facility failed to ensure residents did not receive meals on serving trays in the dining room during the lunch mealtimes. This failure could result in residents having poor self-esteem and decreased quality of life. The findings included: During a dining observation on 05/20/24 at 12:50 p.m., LVN U was observed leaving the plates on the lunch trays in the men's secure unit. During a dining observation on 05/21/24 at 12:38 p.m., LVN U was observed leaving the plates on the lunch trays in the men's secure unit. During an interview on 05/22/24 at 2:00 p.m., LVN U stated she did not know why they left the plates on the trays. LVN U stated she felt like leaving the plates on the trays was easier to contain the mess. LVN U stated it was important to make the residents feel like they're at home. LVN U stated she did not know what the failure to the residents…

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 received appropriate treatment and services to prevent further decrease of ROM for 1 of 4 residents reviewed for range of motion. (Resident #215) The facility did not ensure Resident #215 had a contracture prevention device in place for the treatment of his left hand, wrist, and elbow contracture. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures. The findings included: Record review of Resident #215's face sheet, dated 05/24/2024, revealed Resident #215 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state) and hemiplegia and hemiparesis affecting left non-dominant side (conditions that cause weakness or paralysis on one side of the body). Record review of the Annual MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #13 and Resident #44) reviewed for indwelling urinary catheters and incontinent care. 1. The facility failed to ensure Resident #'s 13 and 44's urinary (foley) catheter was properly secured to his leg. 2. The facility failed to ensure Resident #44 was provided proper incontinent care and catheter care. This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections. 1) Record review of a face sheet dated 5/23/2024 indicated Resident #13 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of senile degeneration of the brain (memory loss/dementia), presence of urogenital implants and obstructive (placement of stents) 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 of 4 residents (Resident #44) reviewed for respiratory care. The facility failed to ensure Resident #44's oxygen was set at 2-3 liters per minute as prescribed by physician. These failures could place residents requiring respiratory care at risk for respiratory infections or complications. Findings included: Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), and obstructive and reflux uropathy (blocked or back flow of urine). Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. The MDS indicated in Section J-Health…

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 dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #215) The facility failed to keep ongoing communication with the dialysis facility and did not ensure the post-dialysis assessments were completed for Resident #215. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #215's face sheet, dated 05/24/2024, revealed Resident #215 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state). Record review of the Annual MDS assessment, dated 05/16/2024, revealed Resident #215 had clear speech and was understood by staff. The MDS revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 20 residents' (Resident #'s 38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening that identified possible triggers when Resident #38 had a history of trauma. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 09/12/2023, indicated Resident #38 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), post-traumatic stress disorder ( a mental health condition…

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 were free of significant medication errors for 2 of 3 residents (Residents #14 and #24) reviewed for pharmacy services. The facility failed to ensure Residents #14 and #24 medications were administered during the scheduled time. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #14's face sheet, dated 05/22/2024, indicated Resident #14 was a [AGE] year-old-male, originally admitted to the facility on [DATE] with a diagnoses which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment of speech, and of muscular coordination, blurred vison and sever fatigue), type 2 diabetes without diabetic neuropathy (chronic condition that affects the way the body processes blood sugar), essential…

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

Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meal (breakfast) reviewed for menus. The facility failed to follow the breakfast menu for residents on 05/22/2024 . This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. Findings included: Record review of the daily menu posted outside the kitchen on 05/22/2024 at 7:00 a.m. indicated the breakfast meal scheduled for that day was: oatmeal, sausage patty, waffle. There was no sign indicating a substitution available from the menu. During an observation on 05/22/2024 at 7:05 a.m. of the steam table assembled with food ready to be plated for the breakfast meal indicated there was no sausage or waffle . During an interview on 05/22/2024 at 12:14 p.m., the Dietician Consultant stated she expected the menu to be followed. The Dietician Consultant stated the Dietary Manager should have contacted her and discussed a substitution since there was no sausage or waffle available. The Dietician Consultant stated it was important 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 record review and interview the facility failed to ensure the arbitration agreement was explained in a form and manner, including a language the resident or representative understood for 1 of 4 residents reviewed for arbitration agreements. (Resident #44) The facility failed to ensure the binding arbitration agreement was fully understood and explained to Resident #44's responsible party, prior to signing it as part of the admission packet. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. The findings included: Record review of the face sheet, dated 05/22/2024, revealed Resident #44 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (brain disorder that causes memory loss, thinking problems and personality changes and gets worse over time), schizoaffective disorder (a mental disorder characterized…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #13) reviewed for hospice services. The facility failed to ensure coordination of care with Resident #13's hospice provider. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included: Record review of a face sheet dated 5/23/2024 indicated Resident #13 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of senile degeneration of the brain (memory loss/dementia), malnutrition, and high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to local law enforcement for 1 of 12 (Resident #2) residents reviewed for abuse, neglect, and misappropriation. HK A withdrew money from Resident #2's bank account. The facility failed to report the misappropriation to the local police and failed to thoroughly investigate the allegation of misappropriation. This failure could place residents at risk of misappropriation. Findings included: Review of a face sheet dated 03/24/24 showed Resident #2 was a [AGE] year-old admitted on [DATE] with diagnoses of senile degeneration of the brain, COPD, and cognitive communication deficit. Resident #2 was his own responsible part. Review of a MDS dated [DATE] showed Resident #2 had a BIMS score of 11, which indicated he had moderately impaired cognition and was alert to person, time, place, and situation. Review of an incident report dated 10/04/23 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 12 residents (Resident #1) reviewed for Quality of Care. LVN A did not document neurological checks were completed after Resident #1 had an unwitnessed fall on [DATE]. The facility failed to ensure neuro checks were completed as ordered. LVN A failed to document Resident #1's use of anticoagulants on the change in condition form given to emergency responders and the hospital when Resident #1 was sent to the hospital due to a change in his condition. These failures could place residents at risk of physical harm or infection. Findings included: Review of a face-sheet dated [DATE] showed Resident #1 was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Hypertension, (high blood pressure) moderate protein malnutrition, Atrial fibrillation, (irregular heartbeat) Tracheostomy Status, (a tube inserted…

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 provide a safe, clean, and comfortable environment for 4 of 4 restrooms reviewed. (Room #'s 1 and 3, 2, 5 and 7, and 6 and 8, and 2) The facility failed to ensure resident room #'s 1 and 3's restroom flooring was not discolored with black colored staining. The facility failed to ensure resident room [ROOM NUMBER]'s restroom flooring was not water stained and discolored, and the toilet caulking was brown and discolored. The toilet seat in room [ROOM NUMBER]'s restroom had worn areas with the wood material visible. The facility failed to ensure resident room #'s 5 and 7's restroom flooring appeared to have water damage and the caulking around the toilet was a brown and black color. The facility failed to ensure resident room #'s 6 and 8's restroom flooring was water damaged, torn, and coming unglued from the concrete floor. These failures could place residents at risk for falls, a diminished quality of life, and a diminished well-kept environment. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure the resident had a right to reasonable accommodations of resident needs for 2 of 2 residents (Resident #'s 3 and 4) reviewed for accommodations of needs. The facility failed to have a bariatric shower chair available for showers for Resident #'s 3 and 4. This failure could place residents at risk for skin irritation, wounds, and a sense of loss of dignity. Findings included: 1) Record review of a face sheet dated 2/13/2024 indicated Resident #3 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, sepsis (severe systemic infection), and morbid obesity. Record review of the consolidated physician's orders dated 2/13/2024 indicated Resident #3 was being treated for MASD (moisture-associated skin damage). The physician's orders indicated on 1/10/2024 Resident #3 was ordered to cleanse bilateral lower extremities with wound cleanser, pat dry, apply ammonium lactate cream daily, and cleanse…

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 consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #2) residents reviewed for notification of change. The facility failed to notify Resident #2's physician when he continually refused his medications. These failures could result in residents with not receiving treatments, supplements, or medications to maintain health. Findings included: Record review of a face sheet dated 2/14/2024 indicated Resident #2 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of stroke, diabetes, kidney disease (stage 4) and absence of a kidney. Record review of an admission MDS dated [DATE] indicated Resident #2 was usually understood and usually understood others. The MDS indicated Resident #2 had no cognition…

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 have evidence alleged violations were thoroughly investigated to prevent further abuse for 1 of 5 residents reviewed for neglect. (Resident #1). The facility failed to ensure a thorough investigation was conducted when Resident #1's family alleged Resident #1 was not provided care on 9/17/2023 from 10:43 p.m. to 5:27 a.m. on 9/18/2023. This failure placed residents at risk for further neglect of the provision of care. Findings included: Record review of a face sheet dated 2/14/2024 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of neurocognitive disorder with Lewy Bodies (a form of dementia with a gradual worsening over time), anxiety, and cognitive communication deficit (impaired functioning of attention, memory, perception, insight and judgement, organization, orientation, and language). Record review of the physician orders dated 9/01/2023 - 11/01/2023 indicated Resident #1 was prescribed…

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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 4 residents reviewed for nutritional status (Resident #1). The facility failed to ensure Resident #1 did not have a significant weight loss in 30 days. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life. Findings included: Record review of a face sheet dated 2/14/2024 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] and discharged on 9/19/2023 with the diagnoses of neurocognitive disorder with Lewy Bodies (a form of dementia with a gradual worsening over time), anxiety, and cognitive communication deficit (impaired functioning of attention, memory, perception, insight and judgement, organization,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 5 residents (Resident #'s 3 and 4) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #3 was scheduled a specialty vision appointment, a cardiology appointment, and a gastrologist appointment as ordered. The facility failed to ensure Resident #4 was scheduled a sleep study and an echocardiogram as ordered. These failures could place residents at risk for inadequate monitoring of their health status. Findings included: 1) Record review of a face sheet dated 2/13/2024 indicated Resident #3 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure,…

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 review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 6 locked doors (employee smoke door and exit door on the northeast hall) reviewed for accidents and hazards. The facility did not ensure the employee smoke door and the exit on the northeast hall remained locked with the alarm engaged. This failure could place residents at risk for injury from elopement to unsafe areas around the facility. The findings included: Record review of the At risk for elopement on open unit list, provided by the facility on 10/07/23, revealed Resident #7 and Resident #8 were at risk for elopement. Record review of the maintenance work orders log for July 2023, August 2023, September 2023, and October 2023 revealed no work orders for door alarms or unlocked doors. During a observation of the facility and interview with the Maintenance Director on 10/06/23 beginning at 10:54 AM, revealed the employee smoke door and the exit on the northeast hall had a red alarm and…

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

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 2 (women's secured unit) medication carts reviewed for storage of medications. The facility did not ensure MA A kept the medication cart on the women's secured unit locked or within her line of site. This failure could place residents at risk for misuse of medication and overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. The findings included: During an observation on 10/06/23 between 10:28 AM and 10:36 AM, the medication cart on the secured unit was unlocked. The medication cart was located behind a half door that was in arms-reach from the desk counter. No facility staff were in eyes view of the medication cart. There were several residents walking around the secured unit. During an interview on 10/06/23 at 10:36 AM, MA A returned to the nurses' desk and stated that was the cart that contained resident's medications. MA A did not lock 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 observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 6 of 21 residents (Resident #2, Resident #7, Resident #29, Resident #44, Resident #54, and Resident #58) and 1 of 1 staff (CNA N) reviewed for resident rights. The facility failed to ensure Resident #2 was treated with dignity and respect when CNA H did not refrain from using his cell phone while assisting Resident #2 with dining. The facility failed to ensure Resident #29's catheter drainage bag was not visible from the hallway. The facility failed to ensure Resident #54, and Resident #58 were served lunch at the same time as the other residents at the table. The facility did not ensure CNA N treated residents with dignity and respect by referring to them as feeders. The facility failed to ensure Resident #7, Resident #44, and Resident #58 were provided with smoke breaks at 5:30 p.m. These…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all allegations of abuse and neglect, had evidence that all alleged violations were thoroughly investigated, and failed to report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 3 of 8 residents (Residents #8, #10, and #264) reviewed for investigating alleged violations of abuse and neglect. 1. Incident investigation regarding Resident #8's allegation of neglect did not have interviews, in-services, or witness statements, attached to the investigation. 2. The facility failed to report evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A), and failed to report the results of the investigation when Resident #10 and Resident #264 had a resident-to resident altercation in the locked unit dining room which resulted in injury to Resident #10. These failures could place…

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 complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 4 of 21 residents (Resident's #9, #51, #164, and #165) reviewed for comprehensive assessments and timing. The facility failed to complete Resident #9, Resident #51, Resident #164, and Resident #165's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their needs identified and met. The findings included: 1. Record review of Resident #9's face sheet, dated 03/08/2023, revealed Resident #9 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain disorder caused by various diseases or toxins that affect the body's chemistry and disrupt the brain's function), type 2 diabetes mellitus without complications (high blood sugar), and schizoaffective disorder (mental health disorder that is marked by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 7 of 21 residents (Resident #13, Resident #26, Resident #51, Resident #53, Resident #54, Resident #57, and Resident #165) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #13 and Resident #26's contractures. The facility failed to care plan Resident #51's use of the psychotropic medication Risperdal (antipsychotic medication used to treat certain mental/mood disorders) and diagnosis of PTSD (Post-Traumatic Stress Disorder). The facility failed to care plan Resident #53's use of the medication Seroquel (antipsychotic medication used to treat certain mental/mood conditions). The facility failed to 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 ensure necessary services to maintain grooming and personal hygiene were provided for 5 of 6 residents reviewed for ADLs. (Resident #9, #11, #12, #44, and #58) 1. The facility failed to ensure Resident #9 received her scheduled showers and facial hair removal. 2. The facility failed to ensure Resident #11 was provided incontinent care and facial hair removal. 3. The facility failed to ensure Resident #12's hair was combed, and nails were cleaned and trimmed. 4.The facility failed to ensure Resident #44 was routinely showered. 5. The facility failed to ensure Resident #58 was routinely showered. These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. The findings included: 1. Record review of Resident #9's face sheet, dated 03/08/2023, revealed Resident #9 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy…

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 received appropriate treatment and services to prevent further decrease of ROM for 3 of 3 residents reviewed for range of motion. (Resident's #8, #13, and #26) 1. The facility did not ensure Resident #8 had a contracture prevention device in place for the treatment of her right contracted hand. 2. The facility did not ensure Resident #13 had a contracture prevention device in place for the treatment of her right contracted knee, left contracted knee, and left contracted hand. 3. The facility did not ensure Resident #26 had interventions in place for his left contracted arm. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures. The findings included: 1. Record review of Resident #8's face sheet, dated 03/08/2023, revealed Resident #8 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia without…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 3 residents (Residents #52, #11, and #22) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: 1. During an interview on 03/06/2023 at 10:36 a.m., Resident #52 stated the food was cold and bland. Resident #52 stated he has been purchasing his own food over the last 8 months due to the food not tasting good. Resident #52 stated he has reported the food complaints to staff but could not remember their names. 2. During an interview on 03/06/2023 at 10:38 a.m., Resident #11 stated the food was too salty and cold sometimes. Resident #11 stated she had mentioned the food complaints to facility staff before but did not remember to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Expired food item was discarded. 3. The microwave was clean and free of food debris. 4. Hair restraints were worn appropriately by dietary staff. 5. The deep fryer was free of grease build up. These failures could place residents at risk for foodborne illness. Findings include: 1. During an observation in the refrigerators and freezers on 03/06/2023 starting at 10:26 a.m. revealed an unlabeled plastic bag with a date 02/27/2023 that was identified by the Dietary Manager as sliced ham; 1 gallon of a liquid substance identified by the Dietary Manager as tea unlabeled and undated; 1 clear container identified by the Dietary Manager as pears unlabeled and undated; 1 container of frozen strawberry slices undated; and 2 gallons of 2% milk…

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 safe and sanitary storage of resident's food items for 3 of 3 residents reviewed for personal food safety. (Resident's #9, #22, and #26) The facility did not implement the personal food policy related to personal refrigerators for Resident's #9, #22, or #26. These failures could place the residents at risk for food borne illness. The findings included: 1. Record review of Resident #11's face sheet, dated 03/07/2023, revealed Resident #11 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), heart failure (progressive heart disease that affects pumping action of the heart muscles), and anxiety disorder (characterized by excessive fear or worry). Record review of the MDS assessment, dated 12/16/2022, revealed Resident #11 had clear speech and was usually understood by staff. The MDS revealed Resident #11 was usually able to understand others. The MDS revealed Resident #11…

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 infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 6 staff (LVN A, LVN B, LVN E, CNA K, CNA V, and CNA X), 1 of 1 shower room (north hall shower room), and 1 of 1 facility reported incident reviewed for infection control. The facility failed to ensure the sharps containers located in the north hall shower room were emptied and not overfilled. The facility did not ensure LVN A performed hand hygiene between glove changes while administrating insulin (helps blood sugar enter the body's cell to be used for energy) to Resident #27. The facility did not ensure LVN B disinfected the wrist blood pressure monitor between Resident #19 and #33. The facility failed to ensure LVN E, CNA K, CNA V, and CNA X wore a face mask properly while in patient care areas. These failures could place residents and staff at risk for cross-contamination and the spread…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents reviewed for right to be informed. (Resident #30) The facility failed to ensure Resident #30 had signed psychotropic consent forms for Risperdal (antipsychotic) and buspirone (antianxiety). This failure could place residents at risk for treatment or services without informed consent. The findings included: Record review of Resident #30's face sheet, dated 03/09/2023, revealed Resident #30 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of anxiety disorder (intense, excessive and persistent worry and fear about everyday situations) and schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #57 and #42) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Residents #57 and #42 were given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: 1. Record review of Resident #57's face sheet, dated 03/08/2023, indicated Resident #57 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions), essential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 3 shower rooms (north hall) and 1 of 22 rooms (room [ROOM NUMBER]) reviewed for a homelike environment. The facility failed to ensure the north hall shower room was clean. The facility failed to repair a missing tile on the wall in front of the toilet in room [ROOM NUMBER]'s bathroom, leaving a hole in the wall. The facility failed to repair a fallen tile on the wall inside of the bathroom by the doorframe in room [ROOM NUMBER], exposing the sheetrock and leaving the tile against the wall in upright position. This failure could place residents at risk for a diminished quality of life and a diminished clean well-kept environment. Findings included: 1.During an observation on 03/06/23 at 11:52 AM, the north hall shower room had feces all over the shower room floor. During an interview on 03/09/23 at 8:06 AM, CNA B stated she walked in the north hall shower room daily because 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 interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 1 residents (Residents#52) reviewed for grievances. The facility did not ensure Residents #52's grievances related to protein bars was resolved. This failure could place resident at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #52's consolidated face sheet dated 03/09/23 indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #52 had a diagnosis of congestive heart failure (the heart does not pump blood as it should), HTN (the force of the blood against the artery walls is too high) and chronic obstructive pulmonary disease (lung disease that blocks the airflow and makes it difficult to breathe). Record review of the MDS dated [DATE] indicated Resident #52 had a BIMS of 12 for mild cognitive impairment. Record review of the grievance and complaint report dated 10/24/22 indicated Resident #52…

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 assessment accurately reflect the status of 1 of 24 residents reviewed for assessment accuracy (Resident #57). The facility failed to accurately reflect Resident #57's weight loss of 5% of more that was indicated on the MDS. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #57's face sheet dated 03/09/23 indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #57 had a diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) and HTN (the force of the blood against the artery walls was too height). Record review of Resident #57's MDS dated [DATE] indicated he had a BIMS score of 2 indicating severe impairment. Resident #57's MDS indicated he weighed 148 lbs. and was on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 3 residents (Resident #4) reviewed for baseline care plans. The facility failed to ensure Resident #4 had a baseline care plan completed within 48 hours of admission This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of a face sheet dated 03/09/2023 revealed, Resident #4 was a [AGE] year-old male admitted on [DATE] with diagnoses of schizoaffective disorder (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), bipolar type, type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential (primary) hypertension (high blood pressure). Record review of Resident #4's assessments…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 2 of 2 residents (Resident #15 and Resident #165) reviewed for activities of daily living. The facility failed to assess Resident #15's and Resident #165's need for communication assistance to effectively communicate with staff. This failure could place residents at risk for decline and diminished quality of life. Findings included: 1. Record review of a face sheet dated 03/09/2023, revealed Resident #15 was an [AGE] year-old-male initially admitted on [DATE] and readmitted on [DATE] with diagnoses of NSTEMI (non-st elevation myocardial infarction- damage of the heart muscle caused by a loss of blood supply due to blocked arteries), Alzheimer's disease (progressive disease that destroys memory and other important 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 observation, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #51) reviewed for accidents, hazards and supervision. The facility failed to ensure LVN C and the DON transferred Resident #51 appropriately with the use of a gait belt. This failure could place residents who require assistance with transfers at risk for falls, pain, and injuries. The findings included: Record review of Resident #51's face sheet, dated 03/09/2023, revealed a [AGE] year-old male admitted on [DATE], with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), Post-Traumatic Stress Disorder, acute (a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), and major depressive disorder, recurrent, severe with psychotic symptoms (a serious mood disorder involving one or more episodes of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 2 residents (Resident #52 and Resident #33) reviewed for respiratory care. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #52. The facility failed to administer oxygen at 2 - 3 liters per minute via nasal cannula as prescribed by the physician and ensure the filter door vents were free of debris for Resident #33. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings Included: Record review of Resident #52's face sheet dated 03/09/23 indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #52 had a diagnosis of congestive heart failure (the heart does not pump blood as it should), HTN (the force of the blood against the artery…

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 pain management was provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 residents reviewed for pain management. (Resident #52) The facility failed to ensure Resident #52 had effective pain management by not making an appointment or attempting to schedule an appointment with pain management after resident was discharged from hospice care. This failure could place resident at risk for increased pain causing undo suffering. Findings included: Record review of Resident #52's face sheet dated 03/09/23 indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. Resident #52 had a diagnosis of congestive heart failure (the heart does not pump blood as it should), HTN (the force of the blood against the artery walls is too high) and chronic obstructive pulmonary disease (lung disease that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 2 of 2 residents reviewed for dialysis services. (Residents #26 and Resident #44) The facility failed to keep ongoing communication with the dialysis facility for Resident #26 and Resident #44. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: 1. Record review of Resident #26's face sheet, dated 03/08/2023, revealed Resident #26 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state), type 2 diabetes mellitus with diabetic neuropathy (high blood sugar that has caused nerve damage), and hemiplegia and hemiparesis affecting left non-dominant side (conditions that cause weakness or paralysis…

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 that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 20%, based on 5 errors out of 25 opportunities, which involved 1 of 4 residents (Resident #19) reviewed for medication administration. The facility failed to ensure Resident #19 received amlodipine besylate 10 mg, ASA 81 mg, doxazosin mesylate 4 mg, vitamin B12 1000 mcg, and vitamin D3 2000 IU between 6:00 a.m. and 8:00 a.m. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #19's order summary report, dated 03/08/2023, indicated Resident #19 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis included memory deficient following cerebral infarction (stroke), essential hypertension (high blood pressure), and CKD (kidneys cease functioning on 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, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts (Nurse Northwest Hall) reviewed for storage of drugs. The facility failed to ensure Northwest Hall nurse cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion. Findings include: During an observation on 03/06/2023 at 11:52 a.m., LVN A left the Northwest Hall medication cart unlocked and out of sight while administering Resident #27's medication. During an interview on 03/06/2023 at 12:00 p.m., LVN A stated she should have locked the medication cart prior to going in Resident #27's room. LVN A stated she was under the impression since the cart was facing the doorway it was ok to keep it unlocked. LVN A stated after she thought about it, she realized her back was turned away from the cart and out of her sight. LVN A stated this…

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 food was prepared in a form designed to meet individual needs for 1 of 1 residents (Resident #165) reviewed for therapeutic diets. The facility failed to ensure Resident #165 received a pureed diet and honey thick liquids as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs). Findings included: Record review of Resident #165's face sheet, dated 03/09/2023, revealed a [AGE] year-old male admitted on [DATE], with diagnoses of profound intellectual disabilities (inability to live independently, needing close supervision, limited communication, and physical restrictions), hypothyroidism (thyroid gland does not produce enough thyroid hormone), and unspecified mood (affective) disorder (mental disorders that primarily affect a person's emotional state). Record review of Resident #165's comprehensive MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 1 of 4 residents (Resident #19) reviewed for accuracy of medical records. The facility did not ensure Resident #19 ASA order had the medication dosage listed. This failure could place residents at risk of not receiving the correct medication dosage. The findings included: Record review of Resident #19's order summary report, dated 03/08/2023, indicated Resident #19 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis included memory deficient following cerebral infarction (stroke), essential hypertension (high blood pressure), and CKD (kidneys cease functioning on a permanent basis). Record review of the MAR dated 03/01/2023-03/31/2023 revealed Resident #19 had an order for ASA with a start date of 08/19/2022. The MAR did not address the medication dosage. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 3 of 5 residents (Residents #53, #21, and #57) reviewed for immunizations. 1. The facility failed to ensure Resident #53's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 2.The facility failed to ensure Resident #21's medical record contained evidence of education on the pneumococcal immunization when the vaccine was administered to the resident. The facility failed to ensure Resident #21's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 3. The facility failed to ensure Resident #57's medical record contained evidence of education on the pneumococcal immunization when the vaccine was administered to the resident. The facility failed to ensure…

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.