Pleasant Springs Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #57) reviewed for quality of life. The facility failed to ensure Resident #57 was assisted with incontinent care in a timely manner after his brief had brownish residue/spots on it and he had a bowel movement on 06/03/2026. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life.Findings included: Record review of Resident #57's face sheet dated 06/04/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (weakness and paralysis of the right side of the body after a stroke),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #67) reviewed for enteral devices. The facility failed to ensure RN H did not administer Resident #67's gabapentin (medication used for nerve pain and seizures) and metoclopramide (medication used to treat nausea, vomiting, and improves stomach emptying) by pushing it through his g-tube (placement of a tube into the stomach used for nutrition and medication administration) with a syringe on 06/01/2026. This failure could affect residents receiving enteral nutrition, medications, and hydration by placing them at risk of health complications.Findings included: Record review of Resident #67's face sheet dated 06/02/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction…

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 4 residents (Resident #31 and Resident #34) reviewed for respiratory care. 1. The facility failed to ensure Resident # 31's nebulizer face mask was placed in a plastic bag, labeled, and dated. 2. The facility failed to ensure Resident #34 oxygen tubing and water humidifier was dated and changed. These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.Findings included: 1.Record review of face sheet dated 06/04/2026 revealed Resident #31 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (degeneration of the brain) and hypertension (high blood pressure). Record review of Quarterly MDS dated [DATE] revealed Resident #31 was usually understood by others and usually understood others. MDS assessment 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 observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 6 residents (Resident #21) reviewed for pharmacy services. The facility failed to ensure MA G did not administer Resident #21's Vitamin C when there was no dosage listed in the physician's order on 06/01/2026. This failure could place the residents at risk of not having medications available for use, medication errors, and inaccurate records.Findings included: Record review of a face sheet dated 06/04/2026 indicated Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side…

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 laboratory services were obtained to meet the needs of 1 of 7 residents (Resident #67) reviewed for laboratory services. The facility failed to ensure Resident #67's Microalbumin (Albumin is a protein needed for tissue growth and healing. It can leak into your urine when your kidneys aren't working as they should) was drawn every 6 months as ordered by the physician.These failures could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. Findings included:Record review of Resident #67's face sheet, dated 06/04/26, reflected Resident #67 was an [AGE] year-old male, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis which included stroke, malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it actually consumes), dysphagia (difficulty or discomfort in…

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, and interviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 residents (Residents #26 and #46) reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 06/02/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.Findings included:During an interview on 05/31/26 at 10:58 a.m., Resident #26 stated the food was served cold. Resident #26 stated she ate in her room mostly for lunch. During an interview on 05/31/26 at 11:21 a.m., Resident #36 stated the food could be a little warmer. Resident #36 stated she ate in her room for lunch. During an observation and interview on 06/02/26 at 12:58 p.m., revealed the lunch tray was sampled by the Dietary Manager and 4 surveyors. The sample tray consisted of barbecue chicken which was lukewarm and dry; the green beans were lukewarm and bland; the macaroni and cheese were lukewarm, bland, and needed more…

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 accommodate residents' food preferences for 1 of 6 residents (Resident #4) reviewed for nutrition. The facility failed to honor Resident #4's preference for no bread for the lunch meal on 05/31/2026 This failure could place residents at risk for a decrease in resident choices, diminished interest in meals, and weight loss.Finding including: Record review of face sheet dated 06/04/2026 revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder (intense mood swings) and type 2 diabetes (metabolic effecting blood sugar control) Record review of Quarterly MDS dated [DATE] revealed Resident #4 was able to make herself understood and was able to understand others. MDS Assessment indicated Resident #4 had a BIMs score of 15 indicating no cognitive impairment. Record review of care plan reviewed on 06/03/2026 revealed Resident #4 had a potential for nutritional problems due to recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that residents who were trauma survivors received 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 3 residents (Resident #1) reviewed for trauma-informed care The facility failed to ensure Resident #1 had an accurate trauma screen that identified she had a history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization.The findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), mild recurrent major depressive disorder (a serious mood…

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

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 4 halls (Hall C), reviewed for a homelike environment. The facility failed to ensure that Hall C was free of offensive odors. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.Findings: During an observation on 02/17/2026 at 10:25 AM, there was an odor of musty urine on Hall C. During an observation and interview on 02/17/2026 at 01:32 PM, there was an odor of musty urine on Hall C. The Housekeeper Supervisor stated she thought it was because one of the residents had incontinent episode in the hallway or maybe it was somebody that had walked by. During an observation on 02/17/2026 at 04:32 PM, there was an odor of musty urine on Hall C. During an observation and interview on 02/18/2026 at 10:32 PM, there was an odor of musty urine on Hall C. While walking down Hall C, CNA T said she could smell a strong odor but was unable to identify the odor. During an interview on 02/19/2026…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure residents were free from abuse for 2 of 8 residents (Resident #5 and Resident #2) reviewed for resident abuse. 1. The facility failed to ensure CNA AA and NA Z provided incontinent care and turning and repositioning for Resident #5 every 2 hours on 02/14/26 and 02/20/2026. 2. The facility failed to protect Resident #5 from verbal abuse when CNA BB spoke to Resident #5 in a degrading manner while providing incontinent care to her on 12/15/2025. 3. The facility failed to protect Resident #2 from physical abuse when the ADON hit Resident #2's hand about three months ago. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: 1. Record review of Resident #5's face sheet dated 02/18/26 indicated she was an [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included dementia (cognitive decline that affects daily life caused by brain cell…

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 implement written policies and procedures that prohibit and prevent mistreatment, neglect, and abuse of residents, for 2 of 8 residents (Resident #2 and Resident #5) reviewed for abuse. 1. The facility failed to implement their abuse policy when the ADON did not report an allegation of verbal abuse to the abuse coordinator after Resident #5's family member reported to her CNA BB spoke to Resident #5 in a demeaning manner on 12/15/25. 2. The facility failed to implement their policy on reporting abuse when Anonymous Staff Member #1 witnessed the ADON hit Resident #2's hand about three months ago and failed to report it to the abuse coordinator. This failure could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.Findings included: 1. Record review of Resident #5's face sheet dated 02/18/26 indicated she was an [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses…

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

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 4 medication carts (A/B Medication Aide Medication Cart, A/B Nurse Medication Cart, and the C/D Medication Aide Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure the A/B Medication Aide Medication Cart and the A/B Nurse Medication Cart were properly secured, when LVN B went to break, left the facility, and left them unlocked and unattended on 02/18/2026. The facility failed to ensure antifungal powder was stored properly, when it was left on top of the A/B Nurse Medication Cart unattended on 02/18/2026. The facility failed to ensure a red pill was disposed of properly, when it was left on top of the C/D Medication Aide Medication Cart This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: During an observation and interview on 02/18/2026…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure:A dented can was stored separately from the undented cans2 opened loaves of bread were stored properly in the dry storage areaAn opened, unsealed carboard box with mushrooms was not stored in the refrigerator directly on top of onions inside a Ziploc bag. These failures could place residents at risk for food contamination and foodborne illness.Findings included: During an observation starting on 02/23/2026 at 7:14 AM, there was an opened, unsealed cardboard box with mushrooms in the refrigerator. The cardboard box was laid directly on top of onions in Ziploc bags. There was a 4 pound 2 ounces dented can of caramel sauce dessert topping stored with the undented cans. There were two open loaves of bread not sealed properly in the dry storage area. One loaf of bread was twisted around and tucked underneath, but it was not…

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 1 of 4 residents (Resident #5) reviewed for dignity. 1.The facility failed to ensure CNA AA treated Resident #5 with respect and dignity when CNA AA provided incontinent care to Resident #5 and did not cover her buttocks when she left the room to gather more supplies on 02/14/26. 2. The facility failed to ensure CNA Q closed the window blinds prior to providing incontinent care for Resident #5 on 02/17/26. These failures placed residents at risk of diminished quality of life, loss of dignity and self-worth.Findings included: 1.Record review of Resident #5's face sheet dated 02/18/26 indicated she was an [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included dementia (cognitive decline that affects daily life caused by brain cell damage),…

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 notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 1 of 5 residents (Resident #6) reviewed for discharge. 1.The facility failed to notify Resident #6's responsible party of his discharge prior to him being discharged from the facility. This failure placed residents at risk of not having an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged . Findings included: Record review of Resident #6's face sheet dated 02/23/26 indicated he was a [AGE] year-old-male who re-admitted to the facility on [DATE] with the diagnoses which included paranoid schizophrenia (a chronic health disorder marked by intense, irrational delusions and hallucinations), diabetes mellitus (condition that causes the blood sugar to be elevated), anxiety (excessive, persistent worry),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #5) and 1 of 3 shower rooms (Hall C shower room) reviewed for infection control practices. 1. The facility failed to ensure CNA S performed hand hygiene and changed gloves when she provided incontinent care to Resident #1 on 02/23/2026. 2. The facility failed to ensure the communal shower room located on Hall C had no soiled towels on the floor or soiled wash cloths on the shower railing, a gown laid folded upon an overflowed trash bin on 02/18/2026. 3. The facility failed to ensure CNA Y covered the 1 of 4 linen carts (Hall A's linen cart) on 02/23/2026. These failures could place residents and staff at risk for cross contamination and the spread of infection. Finding Included: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 5 residents reviewed for pharmacy services. (Resident #1) The facility failed to accurately administer medications for Resident #1 when LVN A, Medication Aide B, and Medication Aide C administered a medication listed as an allergy. This failure could place residents at risk for inaccurate drug administration.Findings Included:Record review of a face sheet, dated 01/12/26, indicated Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including traumatic brain injury (damage to the brain from an external force, like a blow, jolt, or penetrating object, leading to physical, cognitive, emotional, and behavioral changes, ranging from mild (concussion) to severe, affecting brain function, memory, movement, and more, with symptoms sometimes delayed), diabetes, and muscle…

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

Based on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse or CNA when the facility had an average daily occupancy of 60 or more residents for 16 of 30 days reviewed for DON coverage. 1. The facility failed to ensure the DON did not serve as a charge nurse on 10/28/25. 2. The facility failed to ensure the DON did not serve as a CNA on 10/1/25, 10/4/25, 10/09/25, 10/10/25, 10/12/25, 10/15/25, 10/17/25, 10/18/25, 10/19/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/28/25, 10/29/25, and 10/30/25. 3. The facility did not ensure the DON was able to do her designated duty of DON in a 40 hour/week due to performing nurse and CNA duties. These failures could leave residents without the nursing administrative oversight that only the DON can provide.Findings include:Record review of the detailed census report dated 11/4/25 reflected the census was between 66-72 for the month of October 2025.Record review of the ADL task sheet dated October 2025 reflected the DON documenting care activities on 10/1/25, 10/04/25, 10/09/25, 10/10/25, 10/12/25,…

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 ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, clean bed and bath linens for 1 of 1 facility reviewed for resident rights. The facility failed to ensure bed pads (cloth pads placed on the bed to protect mattresses and bedding from incontinence) were available for the residents to use. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: During a confidential group interview on 02/25/2025 at 10:00 AM, the residents said the facility did not have enough bed pads. The residents said when they requested best pads the CNAs told them they did not have enough for them to have one. The residents said they needed the bed pads to help protect their sheets when they had increased episodes of incontinence. During an observation and interview on 02/25/2025 at 3:45 PM, the linen cart on hall A had 1 bed pad,…

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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 23 residents (Resident #7, Resident #8, and Resident #44) reviewed for care plans. 1. The facility failed to ensure a care plan was developed for Resident #8's left arm fracture, use of a sling to the left arm, and refusal to wear her sling. 2. The facility failed to implement Resident #7's care plan for staff to remain outside of the shower for safety. 3. The facility failed to ensure Resident #44's care plan reflected he had weight loss. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 02/26/2025 indicated Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included displaced oblique…

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 Resident #61's face sheet, dated 01/29/25 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), Dementia (memory loss), and diabetes. Record review of Resident #61's quarterly MDS assessment, dated 12/04/24, indicated Resident #61 usually understood and was understood by others. The MDS assessment indicated she had a BIMS score of 03 indicating she was severely cognitively impaired. Resident #61 required total assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS indicated she required oxygen. Record review of Resident #61's physician's order dated 10/04/24 indicated: May have Oxygen at 2-4 liters per minute as needed for shortness of breath to keep sats above 90%. Record review of Resident #61's comprehensive care plan, dated 01/20/25, indicates Resident #61 required…

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 provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 23 residents (Resident # 20 and Resident # 26) reviewed for pharmacy services. The facility failed to ensure Resident #20's blood pressure met the parameters for the administration of an anti-hypertensive medication on 02/06/2025 and on 02/08/2025. The facility failed to ensure Resident #26's blood pressure met the parameters for the administration of an anti-hypertensive medication on 01/12/2025, 01/25/2025, 01/30/2025, 02/08/2025 and on 02/20/2025. These failures could place residents at risk of serious harm, not receiving their medications as ordered, illnesses, hospitalizations, and exacerbation of their disease processes. Findings included: 1.Record review of the face sheet dated 02/26/2025, indicated Resident #20 was an [AGE] year-old female…

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 food that was palatable, attractive, and at a safe and appetizing temperature for 4 of 23 (Residents #64, #38, #12, and #13) residents and 1 of 3 meals reviewed. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #64, Resident #38, Resident #12, and Resident #13, who complained the food was bland and did not taste good. The dietary staff failed to provide food that was palatable for 1 of 3 meals observed on 02/25/25 (lunch) meal. This failure could place residents at risk for weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 02/24/25 at 10:39 a.m., Resident #64 said the food was too salty. During an interview on 02/24/25 at 10:58 a.m., Resident #38 said sometimes the food was not fully cooked; like this morning (02/24/25) the breakfast croissants were not cooked all the way because the bread was doughy. She also said the ham and beans had a lot of salt in them. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to ensure they followed the assessment information about the level of staff needed to meet each resident's needs. This failure could place residents at risk of inadequate care or treatment. Findings Included: A record review of the facility's CMS 802 Resident Matrix dated 02/24/25 revealed the facility census to be 72 residents. During a record review of the facility's assessment dated [DATE] and reviewed by QAPI on 08/21/24, revealed the staffing ratio was for the facility to have 5 aides for 6 am-2 pm, 4 aides for the 2 pm-10 pm, and 4 aides for the 10 pm-6 am shift. During a record review of the Resident's roster given by the Administrator on 02/24/25, it indicated Hall A had 19 residents, Hall B 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 interview and record review the facility failed to ensure the residents or responsible party had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #34) reviewed for psychoactive medications. The facility failed to ensure Form 3713 was filled out completely based on Resident #34's diagnostic criteria, and assessment finding exhibited by the resident for the medication Seroquel, also known as Quetiapine (is an antipsychotic medication that treats several kinds of mental health conditions, including schizophrenia and bipolar disorder. This failure could place residents at risk for receiving unnecessary antipsychotic medications, experiencing potential adverse reactions, and a potential…

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 23 residents (Resident #23) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #23 was appropriately apprised of progress toward a resolution when Resident #23's white pants with black trim, denim shirt with pink cuffs, a blue shirt, and white socks with black and red around the top were not returned from the laundry. This failure could place residents at risk for a decreased quality of life, and grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 02/27/2025 indicated Resident #23 was a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (a group of conditions characterized by a progressive decline in cognitive functions, such as memory, reasoning, and judgment), paroxysmal atrial fibrillation (a type of irregular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 4 residents (Resident #174) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #174's use of oxygen. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #174's face sheet dated 02/26/2025 indicated she was a [AGE] year-old female admitted on [DATE] with diagnoses which included combined systolic and diastolic congestive heart failure (the heart is not pumping blood efficiently which results in fluid buildup in the lungs and body), obstructive sleep apnea (airflow blockage during sleep), and asthma. Record review of Resident #174's Nursing Home PPS MDS assessment dated [DATE] indicated she was understood by others and understood others. 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 ensure a resident who was unable to carry out activities of daily living receives necessary services to maintain personal hygiene were provided for 2 of 72 residents reviewed for ADLs (Resident #58, Resident #70). 1. The facility did not ensure Resident #58 received fingernail care. 2. The facility did not ensure Resident #70 received her showers. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: 1. Record Review of Resident #58's face sheet dated 2/26/25 at 1:43 p.m., indicated Resident #58 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of vascular dementia (reduce blood flow to the brain) with behavioral disturbance, Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to), Pneumonia (an infection that affects one or both lungs), 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 observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #47) reviewed for accidents and supervision. The facility failed to ensure razors were not kept in Resident #47's bathroom. This failure could place residents at an increased risk for injury. Findings included: Record review of Resident #47's face sheet dated 02/27/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of memory, language, and other thinking abilities without behaviors). Record review of Resident #47's Quarterly MDS assessment dated [DATE], indicated she was rarely/never understood and rarely/never understood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 2 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2's family member signed the medication release form for medications which included Ativan (also known as Lorazepam, a controlled medication used for anxiety) on 02/09/2024 and 02/16/2024. The facility failed to ensure Resident #2's Ativan was accurately reconciliated when she returned to the facility on [DATE], 02/18/2024, and 12/15/2024. The facility failed to ensure MA B administered Resident # 1's Eliquis during medication administration on 01/27/2025. These failures could place the residents at risk of not having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to seal, label and date refrigerator and freezer food items. 2) Dietary staff failed to dispose of expired foods items in the pantry and refrigerator. 3) Dietary Staff failed to test the dishwasher to ensure dishwasher chemical levels was at 50 PPM or above. 4) Dietary Staff failed to ensure the chemical strips for the 3 compartment sink were not expired. 5) Dietary Staff failed to ensure the ice machine was cleaned. 6) Dietary Staff failed to clean the juice nozzle. 7) Dietary Staff failed to clean the fryer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During observation of Refrigerator #1 on 1/8/24 at 10:00 a.m., -(1) 2 quart container of Tomato sauce prepared 12/28/23, expired on…

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

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in 19 of 63 Rooms (D hall) reviewed for a clean and homelike environment. The facility failed to ensure (D hall) was cleaned daily, and in accordance with the facility's Housekeeping policy. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings included: During an observation on 1/8/24 at 11:01 a.m., strong urine smell on D hall. During an observation on 1/10/24 at 8:27 a.m., strong urine smell on D hall. During an observation on 1/11/24 at 8:05 a.m., strong urine smell on D hall. During an interview on 1/11/24 at 8:21 a.m., CNA C stated she had been a CNA for 19 years. CNA C stated the urine smell was always strong on D hall all the time especially in the morning. CNA C stated Resident #41 slept in a recliner and was a heavy wetter. CNA C stated Resident #41 was not being toileted like she should be. CNA C stated D hall was the heaviest hall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 20 residents (Resident #16, Resident # 37, and Resident #56) reviewed for comprehensive person-centered care plans. 1. The facility failed to care plan Resident #16's CPAP machine (machine used to deliver constant and steady air pressure to help you breathe while you sleep). 2. The facility failed to care plan Resident #56's contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both hands. 3. The facility failed to ensure Resident # 37 had a fall mat at bedside. These failures could place the residents at increased risk of not having their…

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 are provided care, consistent with professional standards of practices for 5 of 63 residents reviewed for respiratory care (Residents #23, #18, #41, #11 and #16). 1. The facility failed to ensure Resident #23's oxygen was in a bag when not in use. 2. The facility failed to ensure Resident #18 and Resident #41 oxygen concentrator filter was cleaned weekly. 3. The facility failed to ensure Resident #41 nebulizer tubing was placed inside a bag after her breathing treatment was administered. 4. The facility failed to ensure Resident #11's handheld nebulizer was stored in a bag. 5. The facility failed to ensure Resident #16 had an order for his CPAP machine (a machine used to deliver constant and steady air pressure to help you breathe while you sleep) and the facility failed to ensure Resident #16's CPAP mask was stored in a bag. These failures could place residents who require respiratory 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.

Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. The facility failed to provide food that was palatable at the lunch meal on 1/9/24. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the facility week 1 menu dated on 1/9/24, indicated the lunch meal items included Mississippi Pot roast, roasted baked potatoes halves, baby carrots, Honey kissed roll, sticky peach cake, and iced tea. During an interview on 1/8/24 at 10:14 a.m., Resident #14 stated the food was terrible and the food was better with the old company. During an interview on 1/8/24 at 10:49 a.m., Resident #42 stated food was terrible and he had hair in his spaghetti. During an interview on 1/8/24 at 10:50 a.m., Resident #1 stated the food was horrible. During an interview on 1/8/24 at 11:01 a.m., Resident #18 stated she did not like the food, the rice was dry,…

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 3 of 6 staff (CNA B, CNA C, Treatment Nurse) and 2 of 4 Halls (Hall D and Hall A) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while providing wound care to Resident #44. 2. The facility failed to ensure CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #165. 3. The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident # 60 4. The facility failed to ensure the linen carts on Hall D and Hall A were covered. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. During an observation of wound care on Resident #44 with the Treatment Nurse…

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 (Resident #23) reviewed for right to be informed about consents. The facility failed to ensure Resident #23 had signed psychotropic consent for Celexa (antidepressant). This failure could place residents at risk of receiving medications without their prior knowledge or informed consent, or that of their responsible party. The findings included: Record review of Resident #23's face sheet, dated 01/16/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses which included Congestive Heart Failure {CHF} (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), 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 prompt efforts were made to resolve grievances for 1 of 20 residents (Resident #12) reviewed for grievances. The facility did not ensure a grievance was filed for Resident #12's black pants with a bow in the front when it was not returned from the laundry. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #12 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included other secondary Parkinsonism (a condition that causes tremor, muscle movement issues) and atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow without chest pain). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #12 was understood and understood others. The 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 assessments accurately reflected the resident status for 1 of 20 residents (Resident #56) reviewed for MDS assessment accuracy. The facility did not ensure Resident #56's MDS assessment was accurately coded to reflect his limitation in range of motion related to his contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both upper extremities. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1), other reduced mobility, and adult failure to thrive. Record review of the Quarterly 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 interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 3 residents (Resident #45) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #45's use of a blood thinner. This failure could place residents at risk of bleeding, excessive bruising, and not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 01/09/2024 indicated Resident #45 was an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses which included sepsis due to methicillin susceptible staphylococcus aureus (serious infection that can lead to complications and death), arthritis due to other bacteria, right knee (inflammation of the right knee caused by a bacteria, fungus, virus), and chronic kidney disease stage 3B (moderate to severe loss of kidney function). 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 observation, interview, and record review the facility failed to ensure the environment was free of accidents and hazards for 1 of 4 residents (Resident #16) reviewed for safety. The facility failed to ensure Resident #16 did not have an electric heating blanket in his room. This failure could place residents at risk for burns and injuries. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #16 was an 85- year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar) and legal blindness, as defined in USA. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #16 understood others and was able to make himself understood. The MDS assessment indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #56) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #56's urinary (foley) catheter was properly secured to his leg. 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. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #56 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Wernicke's encephalopathy (brain disorder caused by a lock of vitamin B1) and neuromuscular dysfunction of bladder (a type of bladder dysfunction caused by nerve, brain, or spinal cord damage). Record review of the Quarterly 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 interview and record review, the facility failed to ensure residents' who used anticoagulant medications were adequately monitored and free from unnecessary drugs for 2 of 5 residents (Resident #11 and Resident #58) reviewed for unnecessary medications. 1. The facility failed to monitor Resident #11 for side effects of Eliquis (an anticoagulant medication-blood thinner). 2. The facility did not monitor Resident #58 for side effects/adverse reactions for the use of anticoagulant (blood-thinning) medications. This failure could place residents at risk of bruising and bleeding. Findings included: 1. Record review of Resident #11's face sheet dated 01/11/2024 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with routine healing (fracture at the end of the left leg bone), unsteadiness of feet, and paroxysmal atrial fibrillation (irregular heartbeat that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 6.67 %, based on 2 errors out of 30 opportunities, which involved 2 of 7 residents (Resident #60 and #30) reviewed for medication administration. 1.The facility failed to ensure LVN Q administered insulin correctly for Resident #60. 2.The facility failed to ensure LVN O administered insulin correctly for Resident #30. 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 #60's face sheet dated 01/16/24, indicated a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including Diabetes mellites (diabetic), cerebral infarction (stroke), essential hypertension (high blood pressure), and dementia (impaired ability to remember, think, or…

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 6 residents reviewed for medication pass. (Resident #60 and Resident #30) 1. The facility failed to ensure LVN Q administered insulin correctly for Resident #60. 2. The facility failed to ensure LVN O administered insulin correctly for Resident #30 These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1.Record review of Resident #60's face sheet dated 01/16/24, indicated a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses including Diabetes mellites (diabetic), cerebral infarction (stroke), essential hypertension (high blood pressure), and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Record review of Resident #60's quarterly MDS assessment dated [DATE], indicated he understood…

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 drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of the 5 medication carts reviewed for medications storage. (Hall C) The facility failed to ensure Resident #5 and Resident #52's Humalog (fast-acting insulin to control high blood sugar) insulin were taken off the cart after the opening date had expired on Hall C's nurse cart. The facility failed to ensure Resident # 17 Breo Ellipta inhaler (medication used to prevent and decrease symptoms of wheezing and trouble breathing), was dated when opened on Hall C's nurse cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or harm by indigestion. Findings included: During an observation on 01/11/24 at 3:12 p.m., Hall C's nurse's cart revealed Resident #5's Humalog insulin was open and dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 20 residents (Resident #45) reviewed for laboratory services. The facility failed to ensure Resident #45's CBC (complete blood count blood test that measures the number of different types of red blood cells, white blood cells, and platelets), CMP (comprehensive metabolic panel blood test that is used to get a broad assessment of your overall physical health it can check several body functions and processes), ESR (Erythrocyte Sedimentation Rate- blood test that can show if you have inflammation in your body), and CRP (C-reactive protein- blood test that measures the level of a protein called C-reactive protein in the blood which increases when there is inflammation in the body) were drawn on 01/01/2024 and 01/08/2024. This failure could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 4 residents (Resident #27) reviewed for preference. The facility failed to honor Resident #27's preference for no toast. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of a face sheet dated 01/11/2024 indicated Resident #27 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, mild, with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life with other behaviors) and dysphagia, oral phase (difficulty swallowing). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #27 was understood and understood others. The MDS assessment indicated…

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

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for existing staff, consistent with their expected roles for 2 of 21 employees (Dietician and LVN P) reviewed for required annual trainings. The facility failed to ensure the Dietician and LVN P received required restraint and HIV training annually. This failure could place residents at risk for inappropriate restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no required annual restraint training completed for the following staff: *Dietician hired on 11/01/2022 Record review of the employee files revealed there was no required annual HIV training completed for the following staff: *LVN P hired on 12/01/2022 During an interview on 01/11/2024 at 12:09 PM, the Human Resource Specialist stated she expected all staff to have the required trainings. The Human Resource Specialist stated by not having the annual required training on HIV and restraints, the staff would not have the proper education to properly 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.