Accel at Willow Bend

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #1) reviewed for accident hazards/supervision/devices The Facility failed to ensure CNA D used a gait belt correctly when transferring Resident #1 from his wheelchair to the bed and then from her bed back to the wheelchair on 01/06/26. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.Findings included: Record Review of Resident #1's Quarterly MDS assessment, dated 09/17/25, reflected an [AGE] year-old female admitted to the facility on [DATE]. She was severely cognitively impaired with a BIMs score of 3. She required moderate assistance with transfers, toileting, and personal hygiene and required the assistance of 1 person. She was occasionally incontinent of urine and frequently incontinent of bowels. She had sustained one fall without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 3 (Resident #3, Resident #13, Resident #30) of 5 residents reviewed for care planning.1.The facility failed to accurately complete the Physician Orders section on the baseline care plan, to indicate Resident #3 was being admitted to the facility with psychotropic medications.2.The facility failed to have a baseline care plan for Resident # 13 and Resident #30 This failure could place newly admitted residents at risk of not having their needs met, not receiving appropriate medications, not receiving necessary treatments, resulting in poor quality of life. 1) Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plan development. The facility failed to complete Resident #3's comprehensive care plan in a timely manner after his comprehensive assessment was completed. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.Record review of Resident #3's admission MDS Assessment, dated 7/31/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] . Resident #3 had the following diagnoses: Anxiety Disorder, Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood circulation), Heart Failure, Diabetes and Asthma. Section M reflected resident was developing a pressure ulcer. Resident was admitted with the following medications: Antipsychotic, Anticoagulant (blood thinner),…

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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (300 Hall Nurses Cart and 200 Hall Nurses Cart) of 4 medication carts reviewed for pharmacy services in that:The facility failed to ensure: 1- 300 Hall Nurses Cart did not have:o 1 insulin pen for Resident #64 without an open date on 08/19/25. o 1 insulin pen for Resident #58 without an open date on 8/19/25. o 1 insulin pen for Resident #7 without an open date on 08/19/25. o 1 insulin pen for Resident #51 without an open date on 08/19/25. 2- 200 Hall Nurses Cart did not have: o 1 insulin pen for Resident #44 without an open date on 08/19/25. These failures could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications.1- Record review and observation on 08/20/25 at 8:56 AM of the 300 Hall Nurses Cart, with RN A revealed: - The pen…

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 store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in:1. The facility failed to ensure food items in the facility walk-in refrigerator, walk-in freezer and dry storage were dated or labeled.2. The facility failed to ensure food stored in the freezer were properly closed and sealed to prevent exposure to the air. 3. The facility failed to ensure during lunch service kitchen staff used proper hand hygiene while serving residents' trays on 8/19/25.4. The facility failed to take temperatures of all food being served during lunch service on 8/19/25.5. The facility failed to place serving spoons on a sanitized surface during lunch services on 8/19/25.These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination.Observation of the walk-in refrigerator and an interview with the Dietary Manager on 08/19/2025 at 8:47 am…

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 each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section for 1 of 5 residents (Resident #3) reviewed for unnecessary medications.1.The facility failed to have an adequate indication for the use of the medication Quetiapine Fumarate (Seroquel - an antipsychotic) for Resident #3. 2. The facility failed to monitor behaviors and side effects of Quetiapine Fumarate (an antipsychotic) for Resident #3. The failures could place residents at risk of increased behaviors, negative outcomes, adverse reactions and even a decline in health.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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Residents #66, #38) reviewed for care plans.1. The facility failed to develop the following comprehensive person-centered care plans for Resident #66: playing music calmed her her representative preferred her nightstand lamp to stay on at night the need for bilateral (left and right) palm guards due to hand contractures.2. The facility failed to develop a comprehensive person-center care plan that reflected Resident #38 preferred to have her medication placed in her hand,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #56) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #56 had his fingernails cleaned and trimmed on 8/19/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death.), and elevated blood pressure. Resident #56's BIMS score of 14, indicated Resident #56' cognition was intact. The MDS assessment indicated Resident #56 required maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 6 (Resident #66) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #66's contracture to her left hand on 04/22/25. The facility failed to ensure physician orders were written for bilateral ( left and right) palm guards for Resident #66 on admission on [DATE].This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #66 Quarterly MDS assessment, dated 07/20/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (loss of cognition), anxiety (feelings of intense worry), and depression (feelings of sadness/loss of interest).…

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 received appropriate treatment and services to prevent urinary tract infections for one (Resident #41) of two residents reviewed for incontinence care. The facility failed to ensure CNA P provided appropriate perineal care for Resident #41 after an incontinent episode when she failed to clean the resident's labia on 08/19/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections. Record review of Resident #41's Quarterly MDS assessment dated [DATE] reflected Resident #41 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), and elevated blood pressure. Resident #41's BIMS score of 03, indicated Resident #41's cognition was severely impaired. The MDS assessment indicated…

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

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 is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 4 residents (Resident #12) reviewed for quality of care. The facility failed to ensure LVN I followed physician ordered water flushes between each medication administration given via the G-Tube (a feeding tube surgically inserted through a small opening in the abdomen directly into the stomach, used to deliver nutrition, fluids, and medications when a person cannot ingest enough by mouth) for Resident #12 on 08/20/25. This failure could place residents at risk of nausea, shortness of breath and a decrease potential fluid overload. Record review of Resident #12's Comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male with an admission date 11/13/23. Diagnoses included traumatic brain dysfunction (brain dysfunction caused by an outside force), respiratory failure (lungs…

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 #42) residents reviewed for respiratory care. The facility failed to ensure Resident #42's oxygen was administered at the correct setting of 2 liters per minute on 8/19/25 as ordered by the physician. The deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Record review of Resident #42's admission record dated 8/21/25 reflected an [AGE] year-old male with an admission date of 7/6/23. Pertinent diagnoses included seasonal allergic rhinitis (inflammation of sinus) and chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing. Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (200 Hall Nurses Cart) of 4 medication carts reviewed for pharmacy services in that:The facility failed to ensure 200 Hall Nurses Cart did not have 1 insulin pen for Resident #67 with an expired open date on [DATE]. This failure could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications.Record review and observation on [DATE] at 9:27 AM of the 200 Hall Nurses Cart, with LVN I revealed: The pen of insulin Lantus 100 unit/ml for Resident #44 with an expired open date of [DATE]. Observation of the pen reflected it was used. And instruction on the pen reflected to discard after 28 days of use. Interview on [DATE] at 9:45 AM, LVN I stated nurses were responsible to check 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 the attending physician documented in the resident's medical record that the identified drug irregularity had been reviewed and what, if any, action had been taken to address it. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 6 Residents (Resident #66) whose psychotropic medications were reviewed.Resident #66's attending physician failed to address the pharmacist's recommendation to consider a gradual dose reduction. Resident #66 had been receiving Citalopram (antidepressant) 20 mg and Risperidone once a day every day since October 2024 and Alprazolam .25 mg twice a day everyday since October 2024.This deficient practice could contribute to Residents receiving a higher medication dose than necessary and result in adverse side effects.The findings included: Record review of Resident #66 Quarterly MDS assessment, dated 07/20/25, reflected she…

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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #10, Resident #56, and Resident #61) of 5 residents reviewed for infection control. The facility failed to ensure MA N disinfected the blood pressure cuff in between blood pressure checks for Residents #10, Resident #56, and Resident #61. This failure could place residents at-risk of cross contamination which could result in infections or illness. 1.Record review of Resident #10's Quarterly MDS assessment, dated 07/25/25, reflected Resident #10 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included elevated blood pressure, multidrug-resistant organism (microorganisms that are resistant to at least one class of antimicrobial agents, including antibiotics, and wound infection). Resident #3…

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 bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 23 residents (Resident#13, Resident#30, Resident #4) reviewed for resident call system. 1) The facility failed on 08/19/2025 to ensure the call light system was adequately equipped, the call light string was lying on the floor in the shared resident toilets located inside the resident rooms.2) The facility failed to ensure the call light device was within the reach of Resident #4 on 08/19/2025 when the resident was lying in bed in his room. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for activities of daily living.1) Record review of Resident #13's face sheet dated 08/21/2025…

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 that includes written standards, policies, and procedures for the program for 1 (Resident #1) of 4 residents reviewed for infection control. 1. RN (Registered Nurse) A failed to perform proper hygiene during a routine medication administration for Resident #1. RN (Registered Nurse) A knowingly used a syringe that had its plunger seal fall on the ground to administer medication to Resident #1. 2. RN (Registered Nurse) A failed to perform proper Syringe Protocol during routine medication and tube flushing for Resident #1. RN (Registered Nurse) A knowingly continued to use and/or did not change a syringe that he was aware of that had been used for 24 hours to administer a medication, flushing, and placement check 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 residents received services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 5 residents (Residents #18, #25 and #323) reviewed for resident rights. 1. The facility failed to ensure Resident #323's call light was within reach. 2. The facility failed to ensure Resident #25's call light was within reach. 3. The facility failed to ensure Resident #18's call light was within reach. These failures could put residents at risk of not being able to call for assistance, have their needs met, and increases their risk for falls. Findings include: 1. Record review of Resident #323's Quarterly MDS, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #323 had a BIMS score of 12, which indicated moderately impaired cognition. Record review of Resident #323 face sheet,…

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 received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for three of four residents (Resident #5, Resident #44 and Resident #176) reviewed for catheter and incontinence care. 1. The facility failed to ensure the Staffing Coordinator and CNA F maintained the foley catheter drainage bag below Resident #5's bladder during a mechanical lift transfer. 2. The facility failed to ensure CNA G provided appropriate and timely incontinence care for Resident #44 on 07/23/24. 3. The facility failed to ensure the Therapist did not place the urine catheter bag on the floor during the transfer of Resident #176 from his bed to the wheelchair. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. 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.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 carts (Med Aide cart hall 500) reviewed for pharmacy services. The facility failed to ensure LVN S and LVN R, responsible for Med Aide cart hall 500, counted controlled drugs every shift change and signed the narcotic sheet form after the count. This failure could place residents at risk of not having the medication available due to possible drug diversion. Findings include: Record review and observation on 07/22/24 at 8:40 AM of Med Aide Cart halls 500, revealed missing signatures for Off duty and On duty for 07/02/24, 07/03/24, 07/04/24, 07/05/24, 07/06/24, 07/11/24, 07/12/24, 07/15/24, 07/16/24, and 07/18/24 of the narcotic count sheet. Interview on 07/24/24 at 03:06 PM, LVN S stated she should have signed the narcotic sheet after counting the narcotics on 07/11/24, 07/12/24, 07/15/24, 07/16/24, and 07/18/24 because…

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

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food safety. 1. The facility failed to discard food stored in the refrigerator that should no longer be consumed. 2. The facility failed to ensure food item in the walk-in refrigerator had use-by date and labeled . 3. The facility failed to ensure a bin of hard-boiled eggs in the walk-in refrigerator was appropriately covered . These failures could place residents at risk for food-borne illness and food contamination. Findings include: Observation on 07/22/24 at 08:13 AM in facility's walk-in refrigerator revealed a half-used container of chopped garlic in water with an expiration date of 7/3/24. Observation on 07/22/24 at 08:14 AM in facility's walk-in refrigerator revealed a white, cream-like food in one-gallon Ziplock bag that was unlabeled and undated. The zip-lock bag was placed in a medium-size brown corrugated box that had packaged cheese blocks.…

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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 16 residents (Resident #7, Resident #18, Resident #13, Resident#16, Resident#176, and Resident#5) reviewed for infection control. 1. The facility failed to ensure MA L disinfected the blood pressure cuff in between blood pressure checks for Residents #7 and #18. 2. The facility failed to ensure MA M disinfected the blood pressure cuff in between blood pressure checks for Residents #13 and #16. 3. The facility failed to ensure CNA K performed hand hygiene while providing incontinence care to Resident # 176. 4. The facility failed to ensure the Staffing Coordinator performed hand hygiene after completion of a mechanical lift transfer for Resident #5 and prevented cross contamination when the catheter drainage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 one of five (Resident #50) reviewed for comprehensive care plans. The facility failed to ensure Resident #50's care plan was person centered and comprehensive and did not address the resident's resistance to care and resistance to eating and drinking. This failure could place residents at risk of not having individual needs met, not to receive needed services, and negatively impact their psychosocial health and wellbeing. Findings included: Record review of Resident #50's Comprehensive MDS, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included hypertension (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one of six residents (Resident #57) reviewed for ADL care. The facility failed to ensure Resident #57 had her fingernails trimmed. This failure could place residents at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #57's Quarterly MDS assessment, dated 07/10/2024, reflected Resident #57 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension ( high blood pressure) , bipolar disorder (mental illness associated with episodes of mood swings from depressive lows to manic highs), viral pneumonia (infection of the lungs caused by a virus) , chronic pulmonary embolism ( a blockage of pulmonary arteries that happens when a blood clot does not dissolve over…

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 needed respiratory care, including tracheostomy care, was provided such care, including tracheostomy care and tracheal suctioning, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one of one resident (Resident #44) reviewed for tracheostomy care. The facility failed to ensure LVN I maintained a sterile/clean field for supplies necessary for tracheostomy care. The facility failed to ensure LVN I kept her dominant (right) hand sterile while providing trach care and tracheal suctioning for Resident #44. These failures could place residents at risk for respiratory infections. Findings include: Record review of Resident #44's significant change in status MDS assessment, dated 05/25/24, reflected a [AGE] year-old male with an admission date of 11/03/21 and readmission date of 11/13/23. Resident #44 was unable to participate 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 ensure all alleged violations involving neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily 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 one (Resident #1) of 10 residents reviewed for neglect. The facility staff failed to immediately report a 13 hour delay in incontinent care for Resident # 1 to the abuse coordinator. This deficient practice could place residents at risk for not having potential neglect reported and investigated by the abuse coordinator. Findings included: Review of Resident #1's admission MDS assessment dated [DATE] revealed he was [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Critical illness myopathy (significant slowing of the muscle fiber) , hypertension, pneumonia, Diabetes mellitus,…

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 control program designed to prevent the development and transmission of infection for 2 of seven residents (Resident #1 and Resident #3) observed for infection control. The facility failed to ensure: 1-MA BB donned the face mask correctly when she entered Resident#3' isolation room. 2-ADON B and CNA O performed hand hygiene during incontinence care for Resident # 1. These failures could place the residents at risk for infection. Findings include: 1- Review of Resident #3's significant change MDS dated [DATE] reflected Resident #3 was an [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of cancer, heart failure, hypertension, diabetes. Resident #3 required partial/moderate assistance with ADLs except for eating, oral hygiene and upper body dressing. Review of Resident #3's physician order dated 12/28/23 for Resident #3 on droplet precaution for 10 days. Observation on 01/03/24 at 10:57 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to establish and implement policies addressing resident admission to the facility for one (Resident #1) of three residents reviewed for admissions in that: Resident #1 was not provided a signed admission agreement or information upon admission to the facility on [DATE]. Resident was discharged on 12/26/23 without a signed admission agreement. This failure could affect residents by placing them at risk for not being aware of what services the facility is providing. Findings included: Record Review of Resident #1's face sheet dated 12/28/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 12/26/23. Resident #1's diagnoses included hyperlipidemia (high cholesterol), hypertension (high blood pressure), diverticulosis (inflammation or infection in one or more small pouches in the digestive tract), chronic diastolic congestive heart failure (heart's main pumping chamber becomes still and unable to fill properly) 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 provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for two (room [ROOM NUMBER] and room [ROOM NUMBER]) of five bedrooms reviewed for environment, - The facility failed to ensure room [ROOM NUMBER] did not contain a red sticky substance on the floor and oxygen machine - The facility failed to ensure room [ROOM NUMBER] did not have crumbs on the floor, a thick white substance on the floor, and used medical supplies on the bedside table. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: Observation on 12/05/2023 at 11:00 AM revealed room [ROOM NUMBER] had a red sticky substance on the floor and had red substance splashed on the oxygen machine. Interview on 12/05/2023 at 11:00 AM resident #2 revealed she has spilled the red soda on the floor the day before (12/04/2023) and housekeeping had not been in to clean it.…

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 protect the confidentiality of personal health care information for one of three (Resident #1) residents reviewed for confidentiality of records. The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing Resident #1's personal information to include some of her medications. This failure could affect residents by placing them at risk for loss of privacy and dignity. The Findings included: Review of Resident #1's face sheet dated 12/04/2023 revealed a 91 year- old male admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain problem caused by chemical imbalance in the blood), type 2 diabetes (problem with regulating sugar), congestive heart failure problems with the heart muscle) Observation and interview on 12/05/2023 at 11:03 AM of the computer screen on LVN A's medication cart being unlocked for approximately 2-3 minutes while LVN…

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 notify the resident's physician and responsible party when there was a significant change in the physical status for two (Resident #58 and Resident #28 ) of six residents reviewed for notification of changes. 1. The facility failed to notify the physician and responsible party of Resident #58's change of condition of significant weight loss on 05/10/23. 2. The facility failed to notify the physician and responsible party of Resident #28's change of condition of significant weight loss on 05/02/23 and 05/12/23. These failures could place residents at risk for not notifying the physician for a change in condition. Findings included: 1. Review of MDS assessment dated [DATE] for Resident #58 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses of Parkinson's disease (brain disorder that causes unintended or uncontrollable moments), Dysphagia of oropharyngeal phase (difficulty swallowing), Pneumonitis due 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 observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #58 and #61) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan to address Resident #58's significant weight loss interventions of 7.85% for 3 months and 3.5% in 1 week. The facility failed to develop a care plan for Resident #58's behavior of moving about in the night and accidentally disconnecting the feeding pump. 2. The facility failed to develop a comprehensive person-centered care plan to address Resident #61's oxygen therapy use. These failures could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: 1. Review of MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #19, Resident #29, Resident #61) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #19 had his fingernails cleaned and trimmed. 2- Resident #29 had her fingernails cleaned. 3- Resident #61 had his fingernails trimmed and lotion applied to his feet and legs. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1- A record review of Resident #19's Comprehensive MDS assessment dated [DATE] reflected Resident #19 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, cerebrovascular accident (a loss of blood flow to part of the brain, which damages brain tissue), and hemiplegia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents were given the right to participate in the development and implementation of their plans of care for one (Resident #32) of 17 residents reviewed for resident rights. The facility failed to ensure Resident #32 had an opportunity to participate in planning her care. This failure could place residents at risk for decreased quality of care and a lack of notification of services and treatments being provided. Findings included: Review of Resident #32's quarterly MDS assessment dated [DATE] indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #32 was able to understand and able to make others understand her and had a BIMS of 15 which indicated she was cognitively intact. Resident #32 required extensive assistance of two people with all ADLs and rarely got out of bed. Resident #32's active diagnoses included anxiety disorder, functional quadriplegic (complete ability to move due to severe disability or frailty,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to have physician orders for the resident's immediate care for one (Resident #61) of eight residents reviewed for admission physician orders. The facility failed to have a physician order for Resident #61's oxygen use. This failure could affect residents by placing them at risk for not receiving the appropriate care and treatment services. Findings included: Review of Resident #61's face sheet dated 05/17/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of end stage renal disease (kidney failure), generalized muscle weakness, unsteadiness on feet and sepsis (serious condition in which the body responds improperly to an infection). Review of Resident #61's admission MDS assessment dated [DATE] reflected he had a BIMS of 6 indicating he was severely cognitively impaired. He required extensive assistance with ADLs except supervision with eating only. It did not reflect he was…

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 needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #48) of one resident reviewed for respiratory care. LVN D failed to maintain a sterile/clean field for supplies necessary for tracheostomy care and failed to keep her dominant (Right) hand sterile while providing trach care for Resident #48. This failure could place residents with tracheostomies at risk for respiratory infections. Findings included: Review of Resident #48'S's quarterly MDS assessment, dated 03/29/23, reflected a [AGE] year-old male with an admission date of 11/03/21 and readmission date of 11/16/22. Resident #48 was unable to participate in the interview for cognition and was assessed by the staff to be severely impaired. His active diagnoses included pneumonia and tracheostomy (a surgical opening in the neck providing a direct airway 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 observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #29) observed for infection control. Facility failed to ensure CNA N performed hand hygiene while providing incontinence care to Resident #29. This failure could place the residents at risk for infection. Findings include: A record review of Resident #29's Comprehensive MDS assessment, dated 03/30/2023, reflected Resident #29 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, tremor (an involuntary quivering movement), and dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain. Resident #29 had a BIMS of 08 which indicated Resident #29's cognition was moderately…

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.