Legend Healthcare And Rehabilitation - Paris

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 receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 6 residents (Resident #59 and Resident #54) reviewed for pharmacy services. The facility failed to ensure Resident #59's discontinued wrapped in the back of the narcotic box Diazepam (controlled medication used to treat anxiety) was being accurately reconciled on 02/04/26. The facility failed to ensure Resident #54's discontinued wrapped in the back of the narcotic box Lyrica (controlled medication used for pain) was being accurately reconciled on 02/04/26. These failures could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.Findings included:1.Record review of Resident #59's face sheet, dated 02/05/26, indicated a [AGE]…

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

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 4 medication storage areas (300 hall Medication Cart and medication refrigerator) observed for storage and security. 1. The facility failed to ensure MA H secured the 300 hall Medication Cart, when it was not in use and unattended on 02/02/2026. 2. The facility did not ensure Resident #14's medication named Lorazepam (used for anxiety) was secure in the unlocked refrigerator on 02/04/26. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. During an observation and interview starting on 02/02/2026 at 10:31 AM, there was an unlocked, unattended medication cart at the beginning of hall 400. Multiple staff and residents passed by the unlocked, unattended medication cart. At 10:46 AM, the DON observed the surveyor standing by the 300 hall Medication Cart,…

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 2 of 2 residents (Resident #43, Resident #62) and 1 of 1 lunch meal reviewed for palatability. The facility did not provide palatable food served at an appetizing temperature or taste to Resident #43 and #62 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: During an observation and interview on 02/02/2026 at 11:30 a.m., [NAME] M completed temperature checks for all food textures and meal items prior to the start of the tray line and annotated temperatures in the temperature logbook. All temperatures were within acceptable temperature parameters. [NAME] M stated she checked the temperature at the start of the meal and about halfway through the meal service. [NAME] M stated if a resident complained that the meal items were cold, she would retake the…

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

Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 facility. 1. The facility failed to provide a metal container with a self-closing cover device. 2. The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. These failures could place residents and staff at risk of unsafe smoking and injury.Findings included: During an observation on 02/03/26 at 9:30 a.m., there was a 31-gallon galvanized removable lid outdoor trash can with numerous cigarettes butts observed in it. There were numerous cigarette butts laying on the ground. There was no metal ash tray observed in the smoking area. During an interview on 02/04/26 at 4:40 p.m., Maintenance B stated it was ok to dispose of the cigarette butts in the outdoor trash with removable lid because it was a metal container. Maintenance B stated he did not notice the cigarette butts on the ground. Maintenance B stated they should be disposed of in the metal container. Maintenance B stated 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 interview, and record review, the facility failed to ensure in accordance with professional standards and practices, the medical records on each resident were accurately documented for 1 of 7 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure LVN A accurately documented on Resident #1's medical record the time of physician notification in the progress note dated 7/15/25. This failure could place residents at risk of emergency situations not being accurately documented, leading to confusion on what occurred when.Findings included:Record review of the face sheet dated 7/24/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including syncope and collapse (fainting, or sudden temporary loss of consciousness), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (elevated blood pressure), and pulmonary hypertension (a type of 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 conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional for 2 of 4 residents (Resident #13 and Resident #28) reviewed for comprehensive assessments and timing. The facility did not ensure Resident #13's Annual MDS assessment was completed within 14 days of admission. The facility did not ensure Resident #28's admission MDS assessment was completed within 14 days of admission. This failure could place residents at risk of not having their needs identified and met. Findings included: Record review of Resident #13's face sheet dated 11/18/24 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar). Record review of Resident #13's comprehensive MDS assessment, with an ARD of 10/23/24, indicated in Section A0310 it was an Annual assessment (required by day 14). The MDS assessment for Resident #13 indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a resident assessment within the required time frame for 4 of 18 residents (Resident #9, Resident #16, Resident #26, and Resident #31) reviewed for quarterly assessments. The facility did not ensure Resident #9, Resident #16, Resident #26, and Resident #31's quarterly MDS assessments were completed within 14 days of the ARD. This failure placed residents at risk of not having their assessments completed timely which could result in not having their individually assessed needs met. Findings included: 1. Record review of Resident #9's face sheet dated 11/20/24 indicated she was [AGE] years old and admitted to the facility initially on 10/12/21 and re-admitted on [DATE] with diagnoses which included syncope and collapse (fainting or passing out). Record review of Resident #9's MDS assessment, with an ARD of 10/23/24, indicated in Section A0310 it was a Quarterly assessment (required by day 14). The MDS assessment for Resident #9 indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 3 of 16 residents (Resident #173, Resident #16, and Resident #61) reviewed for ADLs. The facility failed to provide scheduled showers and/or bed baths to Resident #173, Resident #16, and Resident #61 at least 3 times per week. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings included: 1.Record review of Resident #173's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of diabetes mellitus type II (condition that happens when the body cannot regulate the way sugar is used as fuel), COPD (a group of lung diseases that cause breathing problems over time), and stage III pressure ulcer to the sacrum (deep wound that involves several layers of skin extending to subcutaneous (fatty)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 6 residents (Resident #66) reviewed for unnecessary medications in that: The facility failed to ensure Resident #66 had documented diagnoses for the use of Humulin R (Regular insulin, also known as neutral insulin and soluble insulin, is a type of short-acting medical insulin. It is used to treat type 1 diabetes, type 2 diabetes, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states). This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medicines) and receiving…

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 a gradual dose reduction was attempted for 3 of 6 residents (Resident #1, Resident #13, and Resident # 37) reviewed for unnecessary medications/ gradual dose reduction in that: 1. The facility failed to ensure a gradual dose reduction (GDR) was attempted or document contraindication for a gradual dose reduction for Resident #1's ordered Risperdal (antipsychotic medication used to treat certain disorders by changing how the brain uses neurotransmitters) 4mg orally twice daily ordered 04/17/2024. 2. The facility failed to ensure a GDR was attempted or document contraindication for a GDR for Resident #13's Risperdal/risperidone 0.5 mg by mouth two times daily ordered on 3/09/23. 3. The facility failed to ensure Resident #37's Haldol and Risperidone (antipsychotic medications that treats several types of mental health conditions, including schizophrenia and bipolar disorder) medication had a specific, appropriate diagnosis for use. 4. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents (Resident #40) reviewed for infection control practices. The facility failed to ensure LVN T performed hand hygiene after blood sugar was taken from a resident. LVN T entered Resident #40's room and did not perform hand hygiene prior to obtaining Resident #40's blood sugar and gave insulin on 11/19/24. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #40's face sheet, dated 11/19/24, indicated she was an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included diabetes Mellitus with hyperglycemia (elevated blood sugar, is a type 2 diabetes that can…

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 an antibiotic stewardship program that included a system to monitor antibiotic use, for 1 (Resident #37) of 18 residents reviewed for antibiotic use. The facility failed to conduct appropriate monitoring of antibiotic use for Resident #37 by not including the resident in the Tracking and Trending Log when he was treated for a urinary tract infection. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #37's face sheet dated 11/18/24 revealed he was [AGE] years old and admitted to the facility initially on 06/04/20 and re-admitted on [DATE] with diagnoses including vascular dementia (a type of dementia that occurs when blood vessels in the brain are damaged, reducing the flow of oxygen and nutrients to the brain), functional urinary incontinence, and stroke. 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to store (1) dented can in a separate area. 4) Dietary Staff failed to effectively reseal, label and date frozen food items. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During observations on 10/09/23 at 9:05 am, the following observations were made in the kitchen walk-in Refrigerator (1 of 1): -(1) bag of lettuce had an open date of 10/2/23 had no expiration, and no receive date. -(2) 1/5 pound of unopened bag lettuce had no receive date and no expiration date. -(1) 4 pound of deli ham placed in a clear zip lock bag had an open date of 10/1/23, no expiration date and no…

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 right to formulate an advance directive was provided for 3 of 22 residents (Residents #124, #5 and #33) reviewed for advanced directives. 1. The facility did not ensure Resident #124's full code status was discontinued after Resident #124 signed a DNR. 2. The facility did not ensure Resident #5's OOH-DNR was signed by the responsible party. 3. The facility failed to obtain a signature from the attending physician and resident representative on Resident #33's DNR form. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #124's face sheet, dated 10/12/2023, indicated Resident #124 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included fracture of second lumbar (lower part of the back) vertebra. Record review of Resident #124's physician order summary report, dated 10/12/2023, indicated an active physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 4 of 22 residents (Resident # 3, Resident #27, Resident #44, and Resident #60) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #60's need for dialysis on the MDS assessment. The facility failed to accurately document smoking for Residents #27 and #3 on the MDS assessment. The facility failed to accurately reflect Resident #44's weight loss on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 10/12/2023 indicated Resident #60 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease with early onset (progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 residents (Resident #32) reviewed for treatment of urinary tract infections and 3 of 4 residents (Resident #12, #64, and #51) reviewed for incontinent care and 1 of 2 residents (Resident #36) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure CNA C used a clean wipe after each stroke while providing catheter care to Resident #12. The facility did not ensure NA Y cleaned Resident #64 peri-anal area before placing a clean brief underneath her and applying barrier cream. The facility did not ensure NA O cleaned Resident #51 front peri area prior to cleaning the peri anal. The facility failed to ensure Resident #32 received teaching regarding proper perineal care to prevent future UTIs. The facility did not ensure Resident #36 foley catheter (connection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 5 of 22 residents (Residents #2, Resident #33, Resident #47, Resident #52, and Resident #55) reviewed for pharmacy services. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. The facility failed to ensure the witnesses signed with the Pharmacy Consultant when drugs were destructed. These failures could place the residents at risk of not having medications available for use and drug diversion. Findings included: 1. Record review of a face sheet dated 10/12/2023 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia (condition where there's 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 ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 4 medication carts (MA 100 hall, Nurse 200 and even rooms on 300 hall, and Nurse 500 hall), 1 of 2 medication storage rooms (Medication room at the beginning of 200 hall) reviewed for drugs and biologicals and for 3 of 22 residents (Residents #59, #14, and #67 ) reviewed for storage of medications. 1. The facility failed to ensure bisacodyl (medication used for constipation) and hydrocortisone acetate (medication used for hemorrhoids) suppositories in the refrigerator in the medication storage room at the beginning of the 200 hall were discarded when they expired. The facility failed to ensure multi-dose bottles of over-the-counter medications on the MA 100 hall medication cart were dated when opened. 2. The facility failed to ensure inhalers (devices used to administer inhaled medications to treat…

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 2 of 6 meals (10/10/23 lunch meal and 10/11/23 lunch meal) reviewed for palatability and temperature. The facility failed to provide food that was palatable for 1 of 3 meal observed on 10/10/23 (lunch) meal. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meal observed on 10/11/23 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During observation on 10/09/23 at 12:40 p.m., the dietary staff served the residents lunch meal trays with only the top plate food warmer only. During observation on 10/10/23 at 7:40 a.m., the dietary staff served the residents breakfast meal trays with only the top plate food warmer only. During a resident council interview on 10/10/23 at 3:33 p.m., Resident # 1, Resident #12, Resident #32, Resident #58 and Resident #61 stated the food was served cold sometimes.…

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 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 3 of 3 residents (Resident #33, Resident #36, and Resident #43) reviewed for hospice services. The facility did not ensure Resident #33's hospice records were a part of their records in the facility. The facility did not ensure Resident #36's hospice records were a part of their records in the facility. The facility did not ensure Resident #43's hospice records were a part of their records in the facility. This failure 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: 1.…

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

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 4 of 6 staff (CNA C, MA S, NA Y, and NA O) reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene in between glove changes. The facility failed to ensure CNA C used a clean wipe after each stroke while providing catheter care. The facility did not ensure NA Y cleaned Resident #64's peri-anal area before placing a clean brief underneath her and applying barrier cream. The facility did not ensure NA Y performed hand hygiene and changed gloves while providing incontinent care to Resident #64. The facility did not ensure NA O changed gloves while providing incontinent care to Resident #51. The facility failed to ensure MA S performed hand hygiene after glove removal and during medication administration. These failures could place residents and staff at risk for…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 3 of 3 residents (Residents #8, 33, and #125) reviewed for antibiotic use. The facility failed to ensure Residents #8, #33, and #125 had documented signs and symptoms, appropriate lab work, and diagnoses to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of Resident #8's face sheet, dated 10/12/2023, indicated Resident #8 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included acute respiratory failure with hypoxia (low level oxygen in the body tissues). There was no…

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 1 dining room reviewed for resident rights. The facility did not ensure LVN A treated residents with dignity and respect by referring to them as feeders. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: During a dining observation on 10/09/2023 at 12:08 p.m., LVN A stated to CNA C, how many feeders were on Hall 200. LVN A was approximately 5 feet from dining room tables where residents were sitting. During a dining observation on 10/09/2023 at 12:12 p.m., LVN A stated to CNA D, MDS Coordinator and a sister facility DON, somebody need to come feed the feeders. LVN A was approximately 5 feet from dining room tables where residents were sitting. During an interview on 10/09/2023 at 1:45 p.m., LVN A stated the word assistance should be used instead of the word feeder. LVN 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 observation, interview, and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 22 residents (Resident #12) reviewed for self-determination. The facility failed to ensure Resident #12 was assisted out of bed. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life. Findings included: Record review of a face sheet dated 10/12/2023, indicated Resident #12 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included chronic diastolic congestive heart failure (condition where the left ventricle of the heart becomes stiffer than normal and can't relax or fill up with blood), type 2 diabetes mellitus with hyperglycemia (chronic condition that affects the way the body processes…

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 provide a safe, clean, comfortable, and homelike environment in 1 of 62 Rooms (room [ROOM NUMBER]) reviewed for a clean and homelike environment. The facility failed to ensure room [ROOM NUMBER] was cleaned daily, and in accordance with the facility's Housekeeping Checklist. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Record review of Resident #40 face sheet, dated 10/10/2023, indicated Resident #40 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included obstructive and reflux uropathy (a condition of the urinary tract), anxiety disorder, hemorrhoids, cognitive communication deficit, history of falling, difficulty in walking, altered mental status unspecified, Hypothyroidism (thyroid gland does not produce enough thyroid hormone) and essential hypertension (high blood…

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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 22 residents (Resident #124) reviewed for care plans. The facility did not develop Resident #124's care plan related code status. This failure could place residents at risk for inaccurate care plans not receiving care and services to meet their needs. Findings include: Record review of Resident #124's face sheet, dated 10/12/2023, indicated Resident #124 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included fracture of second lumbar (lower part of the back) vertebra. Record review of Resident #124's physician order summary report, dated 10/12/2023, indicated an active physician's order for code status: DNR with an order date 09/29/2023 and full code with an order date 09/18/2023. Record review of the admission MDS dated [DATE], 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 2 of 22 residents (Resident #32 and Resident #44) reviewed for comprehensive care plans. The facility failed to ensure Resident #32's care plan was updated to indicate she no longer smoked. The facility failed to ensure Resident #44's care plan was updated to indicate weight loss. These failures could place 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 10/12/2023 indicated Resident #32 was a [AGE] year old female initially admitted to the facility 11/10/2020 and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia (chronic condition that affects the way the body processes blood sugar resulting in high blood sugars), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, 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.

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 services to maintain personal hygiene for 1 of 65 (Resident #46) residents reviewed for ADLs. The facility failed to ensure Resident #46's fingernails were trimmed, clean and free from a black colored material. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings included: Record review of the face sheet, dated on 10/12/23, indicated that Resident #46 was a [AGE] year-old male who admitted to the facility on initial admission dated 8/14/20, with a diagnosis of Cerebrovascular disease (a group of conditions that affect the blood flow and the blood vessels in the brain, Atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), Vascular dementia (reduce…

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 9 residents (Residents #27 and #60) reviewed for respiratory care. 1. The facility failed to ensure Resident #27's oxygen was set between 3-4 LPM as ordered by the physician. 2. The facility failed to ensure Resident #60 had a physician's order for oxygen. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings included: 1. Record review of Resident #27's face sheet, dated 10/12/2023, indicated Resident #27 was an [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged). Record review of the order…

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 were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for 1 of 22 residents (Resident #16) reviewed for physician services. The facility failed to ensure Resident #16 was seen by the facility's attending physician and/or the physician's extender at least once every 60 days from October 2022 through February 2023. This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status. Findings included: Record review of a face sheet dated 10/12/2023 indicated Resident #16 was an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, moderate (a serious mood disorder involving…

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 established smoking policy for 1 of 1 smoking area and 1 of 6 (Resident #27) residents reviewed for smoking. 1. The facility did not ensure Resident #27 had a smoking evaluation completed. 2. The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. These failures could place residents at risk for smoking-related injuries and fires in the facility. Findings included: 1. Record review of Resident #27's face sheet, dated 10/12/2023, indicated Resident #27 was an [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included hypotension (low blood pressure). Record review of Resident #27's admission MDS, dated [DATE], indicated Resident #27 understood others, and made herself understood. The assessment indicated Resident #27 had a BIMS score of 9, which indicated her cognition was moderately impaired. The assessment indicated Resident #27 did not use tobacco.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 2 shower rooms (located on Hall 2) and 1 of 17 rooms (room [ROOM NUMBER]) reviewed for infection control. The facility failed to ensure the shower room (located on Hall 2) was clean and the soiled towels were removed promptly after use. The facility failed to ensure soiled briefs were discarded appropriately from a resident room (room [ROOM NUMBER]). These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 09/26/2023 at 10:22 AM, the shower room commode located on Hall 2 had a brown substance with a strong foul odor on the seat and down the sides. There was a stack of approximately 5 wet towels in the shower stall floor. During…

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.