Cedar Ridge Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect a left heel wound on 06/01/2025. These failures could place the residents at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #1's Face Sheet, dated 06/18/2025, reflected an [AGE] year-old male who initially admitted to the facility 04/29/2025 and re-admitted on [DATE]. Resident #1 had diagnoses which included chronic kidney disease stage 3 (kidneys do not function properly), heart failure (heart does not pump effectively), and pneumonia…

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 comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #1) of four residents reviewed for Care Plans. The facility failed to ensure Resident #1's history of falls were care planned. This failure could place the resident at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #1's Face Sheet, dated 04/30/25, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and dizziness. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/15/25, reflected she had a BIMS score of 10 (moderate impairment). Resident 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 observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #29, Resident #73, and Resident #82) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #29, Resident #73, and Resident #82's rooms were in a position that was accessible to the resident on 01/14/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #29 Review of Resident #29's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with muscle weakness and gait abnormalities. Review of Resident #29's Quarterly MDS Assessment, dated 12/24/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (Rooms #1, #2, #3, #4, #5, and #6) of 10 resident rooms and the hallway floors reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 01/14/25 at 10:35 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. An observation on 01/14/25 at 10:39 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. The bottom of the bedside table had red stains on it. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents' bed was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 4 (Resident #1, #5, #25, and #29) of 5 residents reviewed for physical restraints, The facility failed to obtain physician orders or a physician assessment as of 01/16/25 for Residents #1, #5, #25, and #29, for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free from any physical or chemical restraints. Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 01/16/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included restlessness and irritation, and cerebral palsy (movement disorder). Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #36, Resident #68, and Resident #79) of fifteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #36's care plan for catheter, dated 12/17/2024, had appropriate interventions. 2. The facility failed to ensure Resident #68's care plan for catheter, dated 10/02/2024, had appropriate interventions. 3. The facility failed to ensure Resident #79's care plan for catheter, dated 01/09/2025, had appropriate interventions. These failures could place the residents at risk of not receiving the necessary care and services needed. Findings included: 1. Record review of Resident #36'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 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 residents' goals and preferences for 4 (Resident #16, #28, #40, and #38) of 14 residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #16's breathing mask for her nebulizer (machine that turns liquid medication into a mist breathed directly into the lungs) was properly stored when not in use on 01/14/2025. 2. The facility failed to ensure that Resident #28's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/14/2025. 3. The facility failed to ensure that Resident #40's nasal cannula was properly stored when not in use on 01/14/2025. 4. The facility failed to ensure that Resident #38's nebulizer mask (medication is inhaled through) was properly stored when 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.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure staff were wearing the appropriate hair and beard coverings. 2. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the date the product was received from the vendor. 3. The facility failed to ensure that the sugar and flour bins were cleaned. 4. The facility failed to ensure the ice scoop in the facility kitchen was cleaned. 5. The facility failed to ensure the food in the dry storage area was labeled with the product was received from the vendor. 6. The facility failed to ensure the food stored in the freezer was properly sealed from air-borne contaminants. 7. The facility failed to ensure foods being transported to resident rooms and the memory care unit were properly concealed from air-borne contaminants.…

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 each residents environment remained as free from accident hazards as possible for 1 (Resident #30) of 9 residents reviewed for environmental hazards. The facility failed to ensure Resident #30 did not have pointed scissors in his room on 01/14/2024. This failure could place the resident and other residents who came into the room at risk for injury. Review of Resident #30's Face Sheet, dated 01/16/25, reflected that resident was an [AGE] year-old male initially admitted on [DATE]. Resident #30 had a diagnosis of dysphagia (difficulty swallowing) following other cerebrovascular disease (condition that impacts blood vessels in the brain). Review of Resident #30's Quarterly MDS (tool to assess health and functional capabilities) Assessment, dated 01/13/2025, reflected that Resident #30 had impaired cognition with a BIMS score of 11. Section I did not reflect dementia or a mood disorder. Section I reflected Resident #30 had cognitive…

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 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 two (Resident #36 and Resident #39) of eight residents reviewed for Infection Control. 1. The facility failed to ensure CNA A and CNA B changed their gloves and performed hand hygiene while providing incontinent care to Resident #36 on 01/14/2025. 2. The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #39 on 01/14/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with personal history of urinary tract infections 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 secure confidential and personal medical records for two (Resident #1 and Resident #2) of two residents reviewed for privacy and confidentiality. 1. The facility failed to ensure RN A would close, lock, or minimize her laptop's monitor while administering medications to Resident #1 on 12/17/2024. 2. The facility failed to ensure RN A would close, lock, or minimize her laptop's monitor while providing wound care to Resident #2 on 12/17/2024. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals which could cause a loss of dignity. Findings included: 1. Record review of Resident #1's Face Sheet, dated 12/17/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #1 was diagnosed with neurocognitive disorder with Lewy bodies (a form of dementia) and hypertension. In an observation on 12/17/2024 at 9:30 PM revealed RN A was passing…

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

Based on observations, interviews, and record review, the facility failed to ensure that one cart (wound care cart) of five carts observed was kept locked or under direct observation of authorized staff in an area where residents could access it. The facility failed to ensure that RN A locked her wound care cart before providing wound care on 12/17/2024. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications. Findings included: Observation on 12/17/2024 at 11:17 AM revealed RN A was about to perform wound care. She prepared the things needed and went inside the resident's room. She left the wound care cart unlocked. The drawers of the wound care cart were facing the hallway. The drawers contained different types of dressings, different sizes of dressings, wound cleansers, normal saline, ointments, gauze pads, bandages, tongue depressors, and tape measures. In an interview with RN A at 11:31 AM, RN A stated the cart should not be left open everytime care was provided. She said she forgot to lock her 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #3) of five residents reviewed for Infection Control. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #3 on 12/17/2024. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: Record review of Resident #3's Face Sheet, dated 12/17/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #3 was diagnosed with chronic kidney disease. Record review of Resident #3's Comprehensive MDS Assessment, dated 12/01/2024, reflected the resident had a moderate impairment in cognition with BIMS score of 08. Resident #3's Comprehensive MDS Assessment…

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 record reviews and interviews, the facility failed to employ a certified Dietary Manager or a qualified fulltime dietitian or other clinically qualified nutrition professional for the facility's only kitchen. The facility failed to ensure the Dietary Manager met all required state guidelines or employed a full-time dietician, who also assisted in managing the facility kitchen's daily food and nutrition services. This failure could impact a resident's ability to receive acceptable and appropriated food and nutrition services. Findings include: Record review of the facility's documents for a Qualified Dietary Manager revealed the Dietary Manager had not completed qualified certification course that met the requirement of a qualified nutrition professional . The Dietary Manager and facility produced a college enrollment form for the Dietary Manager courses starting from 03/15/23 and completing on 06/20/24. Interview with the Dietary Manager on 11/30/23 at 02:05 PM, she stated she was a cook at the facility before being promoted to the Dietary Manager in March 2023. She stated…

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

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 13 (Resident #'s 1, 4, 7, 10, 11, 18, 19, 22, 37, 43, 54, 59, and 69) of 27 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #'s 1, 4, 7, 10, 11, 18, 19, 22, 37, 43, 54, 59, and 69's rooms were cleaned, sanitized, and maintained. 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 : Observation of Residents #37 and #54's room on 11/28/23 at 11:09 AM revealed the windowsill had a lot of dead gnat (too numerous to count) on the ledge on the windowsill. The top of the air-conditioned unit had dead gnats and dirt particles along the vents. The bathroom had a bag of trash sitting near a trash can and a bag of wipes were lying on the floor near 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, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled ( labeled identifying items in the container) and dated ( the use by date was not documented) according to guidelines and in a sanitary manner. The facility failed to ensure damaged foods were discarded according to guidelines. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 11/28/23 from 09:15 AM to 09:25 AM in the facility's only kitchen revealed: Six individually wrapped ham and cheese sandwiches were undated in the refrigerator. Five large pitchers of juices were unlabeled and undated in the refrigerator. One large, long tube of ground beef, in its original packaging, in the refrigerator and was undated . Seven small bowls…

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 obtain from hospice the most recent hospice plan of care specific to each patient needs for 1 of 3 residents (Resident #59) reviewed for hospice services. The facility failed to ensure Resident #59's hospice care was care planned. This failure could place residents at risk of needs not being met. Findings include : Record review of Resident #59's Face Sheet, dated 11/30/23, revealed he was a 93 -year-old male admitted on [DATE]. Relevant diagnoses included Permanent Atrial Fibrillation (irregular heartbeat), and Rheumatic Tricuspid Insufficiency (heart valve complications ). Record review of Resident #59's records in the facility's system of records indicated the resident was moved to hospice services on 10/12/23 . Review of Resident #59's Comprehensive Care Plan revised on 08/24/2023 reflected no care plan for hospice care. Interview on 11/30/23 at 11:45 AM with Social Services, she stated she that it was primarily the MDS Nurse's responsibility 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 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 2 (Resident #20 and Resident #39) of 4 residents reviewed for incontinence care. 1. The facility failed to ensure CNA B performed hand hygiene while providing incontinence care to Resident #20. 2. The facility failed to ensure CNA C performed hand hygiene while providing incontinence care to Resident #39. This failure could place residents at risk of cross-contamination resulting in infections. Findings include: 1. Review of Resident #20's MDS assessment, dated 09/14/23, reflected the resident was a [AGE] year old female admitted to the facility on [DATE]. Her cognitive status was severely impaired. She was always incontinent of bladder and bowel. Her diagnoses included diabetes and Alzheimer's disease. An observation 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 a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 1 of 3 residents (Resident #8) reviewed for quality of life. The facility failed to provide Residents #8 with routine showers. These failures could place residents at risk for and a decreased quality of life. Findings included: 1. Record review of Resident #8's MDS assessment, dated 10/03/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included heart failure, renal failure, diabetes, seizure disorder, obesity. Section G of the MDS which described care required for bathing was not completed. Record review of Resident #8's Care Plan, dated 07/09/22, reflected: The resident had an ADL self-care performance deficit related to activity intolerance, impaired balance, and limited mobility. Facility interventions…

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 provide an environment that was free from accident and hazards to prevent accidents for 1 (Resident #10) of 6 residents reviewed for accidents free of hazards. The facility failed to ensure Resident #10 had a smoking assessment completed since admission to the facility on [DATE]. This failure placed the residents at risk of accidents and hazards. Findings Included: Record review of Resident #10's Face Sheet, dated 11/30/23, revealed she was an 89 -year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting and atrophy, mild cognitive impairment, and lack of coordination. Record review of Resident #10's MDS dated [DATE] revealed the resident's BIM was 05 (Severe Cognitive Impairment). Record Review of the Resident #10's Care Plan dated 10/23/23 revealed the resident was care planned for being a smoker and an intervention included evaluating the resident for safe smoking. Record review on 11/29/30 for Resident #10's smoking assessment…

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 maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #13) reviewed for nutrition and hydration. The facility failed to assess Residents #13's weight on a weekly basis per the resident's care plan and the resident experienced an 11% weight loss in a 3-month period. This failure could place resident at risk of experiencing a decline in health due to malnutrition. Findings included: Review of Resident #13's MDS assessment, dated 10/13/23, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE]. Her cognitive status was severely impaired. The resident's diagnoses included anemia, osteoporosis, non-Alzheimer's dementia, and malnutrition. Her weight was 78 pounds and 63 inches tall. The resident was on a pureed diet. Record review of Resident #13's Care plan, revised 07/27/22, reflected the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 (Residents #2) of 4 residents reviewed for ADL's. 1. The facility failed to ensure Resident #2 was getting assistance with changing her brief and catheter care as needed. This failure had the potential to affect residents by placing them at risk for skin breakdown and a decline in their quality of life. Findings included: Review of Resident #2's MDS assessment, dated 08/22/23, reflected she was a [AGE] year-old-female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included morbid obesity and chronic obstructive pulmonary disease. She was always incontinent of bladder and bowel and had an indwelling catheter. Review of Resident #2's Physician's Orders, dated 09/13/23 reflected a new order (following Surveyor intervention) was written for: Change…

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 incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of three residents observed for infection control. CNA A failed to ensure Resident #1's Foley catheter did not pull or hang from the resident during incontinence care. This failure could place residents at risk for infection and or trauma at the catheter site. Findings included: Review of Resident #1's MDS, dated [DATE], reflected he was admitted on [DATE]. He was 72 years' old. He had a diagnosis of stroke. The resident was incontinent of urine and stool and had an indwelling catheter . An interview and observation on 09/13/23 at 11:55 AM with Resident #1 revealed he was lying in bed with his blanket pulled back. He was alert and able to answer questions. He was wearing a brief and was incontinent of a large amount of stool that was spilling…

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 one (Resident #1) of three residents observed for infection control. CNA A failed to perform hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Review of Resident #1's MDS, dated [DATE], reflected he was admitted on [DATE]. He was 72 years' old. He had a diagnosis of stroke. An interview and observation on 09/13/23 at 11:55 AM with Resident #1 revealed he was lying in bed with his blanket pulled back. He was alert and able to answer questions. He was wearing a brief and was incontinent of a large amount of stool that was spilling from his brief. He said he was waiting for staff to come…

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.