Colonial Manor Advanced Rehab & Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews the facility failed to ensure a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, and maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise, for 2 (Resident #1 and Resident #2) of 7 residents, reviewed for nutritional status.The facility failed to ensure Resident #1 and Resident #2 were weighed weekly per physician's orders. This failure could place residents at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.Findings included:1. Record review of Resident #1's face sheet, dated 05/28/26, reflected an [AGE] year-old female, admitted on [DATE] diagnoses included: other fracture of left patella…

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 stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 medication carts (400 hallway cart) reviewed for medication storage. The facility failed to ensure a medication named Normal Saline flush was not sitting on top the unattended 400 hall medication cart on 3/12/26 at 3:45 p.m. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: During an observation on 05/12/2026 at 3:45 p.m., revealed on top of the unattended 400 hall medication cart, there was a saline flush. During an interview on 05/12/2026 at 3:50 p.m., with LVN A she said normal saline flush should have been inside the medication cart and locked. She said a resident could take the normal saline, other residents or visitors. She said residents could have an allergic reaction or the normal saline flush could get contaminated. During an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 3 residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure CNA B and CNA C used the required personal protective equipment for Resident #1, who was on enhanced barrier precautions due to feeding tube during incontinent care on 05/13/26. 2. The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #1 on 05/13/26 and failed to ensure CNA B and CNA C performed hand hygiene for at least 20 seconds. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: Record review of Resident #1's face sheet dated 05/13/26 reflected a [AGE] year-old female with and admission date 08/16/19. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 3 residents reviewed for respiratory care.The facility failed to ensure Resident #1's oxygen was administered at the prescribed setting of 3 liters per minute on 3/19/2026 as ordered by the physician.This deficient practice could place residents at risk of developing respiratory complications and a decreased quality of care. Findings included:Record review of Resident #1's admission record, dated 3/19/26, indicated a [AGE] year-old female with an admission date of 3/12/2026. Resident #1's diagnoses included chronic pulmonary edema (a long-term condition where fluid slowly builds up in the lung's air sacs, making it hard to breathe), acute respiratory failure with hypoxia (a condition defined by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 4 residents reviewed for quality of care (Resident #1).The facility failed to respond to Resident #1's call light to provide care for 1 hour and 45 minutes on 12/25/2025.This failure could place residents at risk for a delay in care and services. Findings included:Record review of Resident #1's face sheet dated 1/15/2025 indicated a [AGE] year-old female with an admission date of 7/17/2024. Resident #1's diagnoses included: Hemiplegia and Hemiparesis (paralysis or weakness to one side of the body) affecting left non-dominant side, Contracture of Muscle (muscle in a tight position, making it hard to move) Left Hand, Lack of Coordination, Schizoaffective Disorder (intense mood swings and reality-bending psychotic episodes), Epilepsy (brain disorder causing recurring seizures).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 each resident the right to be free from abuse for two residents (Resident #2 and Resident #3 ) of 6 residents reviewed for abuse. The facility failed to protect R #2 and R #3 from being hitting each other on 10/15/25 as they passed each other in the hallway. These failures have the potential to place residents at risk of serious injury and continued abuse.The Findings Include: Resident #2 Record review of R #2 face sheet revealed an [AGE] year-old male initially admitted on [DATE] and then readmitted on [DATE] with diagnosis of physiological condition(the internal physical and chemical states of a living organism that affect its bodily functions, ranging from maintaining homeostasis to experiencing illness or stress, Dementia (A group of thinking an social symptoms that interferes with daily functioning), and Insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or both, leading to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting injuries of unknown origin. The facility failed to report within 2 hours to Health and Human Services Commission when Resident #1 was found on the floor on [DATE] at 3:30am with a laceration to forehead that the resident was unable to explain and was not witnessed and required her to be sent to the hospital. This failure could place residents at risk for undetected abuse, neglect and/or decline 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 received services in the facility with reasonable accommodation of each resident's needs, for one Resident (Resident #71), of twenty-four residents reviewed for call light access. Resident #71's call light was placed out of reach of Resident #71 while in bed. This failure could place residents on at risk for not being able to call for assistance from staff. The findings were: Record review of Resident #71's admission Record, dated 04/22/25, revealed Resident #71 was [AGE] year-old hospice resident and was admitted to the facility on [DATE]. Resident #71's diagnoses included encephalopathy (any disease or disorder of the brain, specifically one that causes dysfunction), dementia (a group of thinking and social symptoms that interferes with daily functioning), cerebral infarction (stroke), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and congestive heart…

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 the assessment accurately reflected the resident's status for 1 (Resident #79) of 6 residents reviewed for accuracy of assessments. The facility failed to identify Resident #79 was receiving Dialysis on his Quarterly MDS assessment dated [DATE]. This failure could place residents at risk for receiving inadequate care and services based on inaccurate assessments. The findings included: Record review of Resident #79's admission record dated 03/05/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Dependence on Renal Dialysis, End Stage Renal Disease (a long-term condition where the kidneys gradually lose their ability to filter waste products from the blood), and Type 2 Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, was too high). Record review of Resident #79's Quarterly MDS dated [DATE] revealed: BIMS score of 03 indicating Resident #79 was severely cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #22) residents reviewed for respiratory care. The facility failed to ensure Resident #22's oxygen was administered at the correct setting of 2 liters per minute on 04/22/2025 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #22's admission record dated 04/22/2025 reflected an [AGE] year-old female with an admission date of 10/01/2019. Pertinent diagnoses included Shortness of Breath, Muscle Wasting and Atrophy (loss of muscle tissue), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #37) of 1 observed for incontinent care, in that: CNA A did not use one wipe per swipe on the penile area during incontinent care on Resident #37. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #37's admission Record, dated 04/22/25, revealed Resident #37 was 87 years-old hospice resident and was admitted to the facility on [DATE]. Resident #37's diagnoses included type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause airflow obstruction and breathing problems), atrial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #1) of 1 observed for incontinent care, in that: CNA A did not use one wipe per swipe on the buttock area during incontinent care on Resident #1. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #1's Face Sheet dated 03/18/25, reflected a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), anoxic brain damage (damage or death of brain cells due to lack of oxygen), spastic quadriplegic cerebral palsy (a movement disorder where the muscles of all four limbs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 Residents (Resident #2, Resident #3) reviewed for medical records accuracy, in that: 1.Resident #2's June 2024 Medication Administration Record documentation record was incomplete. Staff did not document or sign off on the administration of physician ordered insulin. 2.Resident #3's June 2024 Medication Administration Record documentation record was incomplete. Staff did not document or sign off on the administration of physician ordered insulin. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: 1. Record review of Resident #2's face sheet, dated 06/10/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, 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 3 of 6 Residents (Resident #2 and Resident #5 and Resident #6) that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1. CNA C failed to don the appropriate PPE before he entered Resident #2's room. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. The findings include: 1. Record review of Resident #2's face sheet, dated 06/10/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: COVID-19 (Contagious respiratory disease caused by severe acute respiratory syndrome coronavirus 2), type 2 diabetes mellitus with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish 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 two residents (Resident #85 and Resident #91) of four residents observed for infection control issues, in that: 1. The CNA A and CNA B did not wash their hands for a minimum of 20 seconds while performing incontinent care on Resident #85. 2. The CNA D removed her dirty gloves and applied clean gloves without sanitizing hands between glove changes while performing incontinet care on Resident #91. These deficient practices could place residents at-risk for infection due to improper care practices. The findings were: 1. Record review of Resident #85's admission Record, dated 02/17/24, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: End stage renal disease (or kidney failure, occurs when 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 interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for for 1 of 6 residents (Resident #39) reviewed for abuse/neglect. The facility did not report Resident #39's had an unwitnessed fall on 01/27/24. Resident #39's lying on the floor next to the toilet and her head in the bathroom shower. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect. The findings included: Record review of Resident #39's file reflected an [AGE] year-old female, with an original admission date of 01/17/2022. Her diagnoses included: Osteoporosis (bones become weak and brittle) left knee, history of falling, contusion (a bruise from the result of a direct blow or impact, such as a fall) of other part of head, fall on same level,…

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 incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 6 residents (Resident #85) reviewed for quality of care, in that: The facility failed to ensure Resident #85's indwelling catheter was not pulled or tugged on during incontinent care that would cause pain or discomfort. This failure could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care. The findings were: 1. Record review of Resident #85's face sheet, dated 02/17/24, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: End stage renal disease (or kidney failure, occurs when the kidneys can no longer support the body's needs), dialysis (a procedure to remove waste products and excess fluid from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 1 of 3 residents (Resident # 103) reviewed for quality of care in that: Resident #103's oxygen was administered at 2.5 Liters Per Minute instead of 3 Liters Per Minute via trach mask as ordered by physician. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care. The findings included: Record review of Resident #103's face sheet dated 02/17/24, reflected he was a [AGE] year-old male who was initially admitted on [DATE]. Resident #103's relevant diagnoses were generalized epilepsy, quadriplegia (form of paralysis that affects all four limbs plus torso), diabetes, meningitis, hydrocephalus (excess fluid build-up in fluid-containing cavities of the brain), hypertension, acute respiratory failure, tracheostomy ( a hole that surgeons make through 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 record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 (Resident #22) of 5 Residents, reviewed for pharmacy services in that: The facility failed to ensure that Resident #22 did not receive an antipsychotic (Risperdal/risperidone) that was not necessary to treat Vascular Dementia. This failure could affect residents who received medications in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The findings included: Record review of Resident #22's face sheet reflected an [AGE] year-old female with an admission date of 01/24/2024 and original admission date of 05/21/2014. Her diagnosis were Vascular Dementia, Parkinson's, Acute Kidney Failure, Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Bipolar disorder, Cerebrovascular Disease (a group of conditions that affect blood flow in the…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure equipment was clean and sanitized 2. The facility failed to maintain cleanliness of the floor in the kitchen These failures could place residents at risk of foodborne illnesses. The findings included: An observation of the kitchen on 02/13/2024 at 8:45 a.m. revealed the floor behind the stove, oven, and fryer had debris behind it. The kitchen's hand washing sinks had a whitish substance adhered to the faucets, and backsplash. The seal around the strainers had a rusty color. The faucets spout had a whitish, and brownish substance around it. The fryer had a white substance adhered to the side and front panels. The oven had a whitish substance adhered the front and side panels. The oven doors had a thick brown substance adhered to them. The paper towel dispenser had a thick brown film on top and on the front panel. 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 interview, and record review, the facility failed to ensure medical records were accurately documented, for one Resident (Resident #39) of six residents reviewed for accuracy of medical records. The facility failed to document Resident #39's falls in the Progress Notes. This failure could place all residents with falls at risk of not receiving adequate care and services. The findings were: Record review of Resident #39's admission Record file reflected an [AGE] year-old female, with an original admission date of 01/17/2022. Her diagnoses included: Osteoporosis (bones become weak and brittle) left knee, history of falling, contusion (a bruise from the result of a direct blow or impact, such as a fall) of other part of head, fall on same level, hypertension (high blood pressure), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), cognitive communication deficit…

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 require dialysis receive such services, consistent with professional standards of practice, the comprehensive person -centered care plan, and the residents' goals and preferences, for 4 of 5 residents (R #2, R #3, R #4, R #5) reviewed for care plans, in that: The facility did not follow R #2, R #3, R #4, and R #5's care plans which indicated to obtain monthly labs from dialysis center and place in the resident's chart every day shift every 30 days. The facility failed to obtain the labs for the following months: September 2023-January 2024 for R #2, November 2020-November 2023 and January 2024 for R #3, July 2023 and August 2023 for R #4, January 2023-April 2023, and June 2023-December 2023 for R #5. This failure could place residents at risk of not receiving the care and services as indicated in the comprehensive care plans. The findings included: Record review of R #2's face sheet reflected an [AGE] year-old female with original…

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 all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately to the State Survey Agency, within two hours, if the events that cause the allegation involve abuse or result in serious injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 resident (Resident #1) of 3 residents reviewed for abuse/neglect, The facility did not report the allegation of resident abuse to the State Survey Agency within the allotted time frame for Resident #1 who had been administered CBD and THC oil by FM I. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect. The findings included: Record review of Resident #1's face sheet dated 01/10/2024 reflected she was a [AGE] year-old female who was admitted to facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to review Resident #1's progress notes after NP C documented on progress notes on 12/20/23 that FM I was interested in administering CBD to Resident #1. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life, and hospitalization. The findings included: Record review of Resident #1's face sheet dated 01/10/2024 reflected she was a [AGE] year-old female who was admitted to facility on 11/17/2023, relevant diagnoses were cerebral infarction (disrupted blood flow to the brain), congestive heart failure (when the heart does not pump blood as well as it should), tracheostomy (a hole that surgeons make through the front of the neck and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided, met professional standard of quality for 1 (Resident #1) of 5 residents reviewed for professional standards. The facility failed to implement Resident #1's physician's order for treatment of her right arm blisters. This failure could place residents at risk of not receiving the care and services ordered by the physician and a decline in health status. Findings included: Review of Resident #1's face sheet dated 09/11/23 reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), other skin changes, type 2 diabetes mellitus without complications (high blood sugar), essential (primary) hypertension (high blood pressure), pressure ulcer of sacral region, stage 4 (skin injury near the lower back and spine), personal history of transient ischemic attack (stroke that only last a few minutes/Interruption of blood supply to…

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