Windsor Nursing And Rehabilitation Center Of Raymo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews 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 need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans.1.The facility failed to ensure Resident #1's care plan included he was under EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities) due to having an Indwelling/foley catheter.2.The facility failed to ensure Resident #1 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact…

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 maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 2 residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #1 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities). This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health.The findings included:Record review of Resident#1's admission sheet, dated 01/21/26, revealed a [AGE] year-old male with an admit date of 12/15/25 and an original admission date of 05/29/24. His relevant diagnoses included; dementia (a progressive aging condition involving significant 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 on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) residents reviewed for EBP.The facility failed to ensure CNA A wore proper PPE during peri-care for Resident #1 who required enhanced barrier precautions (EBP). This failure could place residents at risk of MDRO contamination. The findings included: Record review of Resident#1's admission sheet, dated 01/21/256, revealed a [AGE] year-old male with an admit date of 12/15/25 and an original admission date of 05/29/24. His relevant diagnoses included; dementia (a progressive aging condition involving significant cognitive decline-memory loss, impaired language, and behavioral changes), bladder-neck obstruction (blockage where the bladder's opening to the urethra doesn't open properly during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is 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, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. CNA A failed to report an allegation of abuse to the Administrator involving Resident #1 being tucked into bed with a blanket tucked behind her shoulders sometime in March of 2025. This failure could place residents at risk for undetected…

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 4 (Resident #161, Resident #33, Resident #53, and Resident #15) of 8 residents observed for infection control. 1. The facility failed to post the enhanced barrier precaution sign and no PPE gowns noted in the room or nearby Resident #161's room. 2. During Gtube medication administration for Resident #33, RN K did not sanitize hand after touching the privacy curtain. Then while wearing gloves, he touched the bed remote and with the same pair of gloves, he proceeded to touch the residents Gtube. 3. CNA F failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #53. 4. The facility failed to change gloves and perform hand hygiene when moving from a clean to a dirty area during wound care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 7 Residents (Resident #5 and Resident #12) who were observed for ADL care. 1. CNA D stood while feeding Resident #5 her lunch meal on 12/2/24. 2. CNA D stood while feeding Resident #12 her lunch meal on 12/2/24. These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable and could place residents at risk of embarrassment, lack of privacy, and loss of dignity. The findings were: Review of Resident #5's face sheet, dated 12/3/24, revealed she was initially admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions), Chronic Obstructive Pulmonary Disease (A group of lung…

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 a safe, functional, sanitary, and comfortable environment for 2 of 8 residents (Resident #157 and Resident #27), staff, and the public in that: The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied room for Resident #157 and Resident #27. This failure could affect residents by placing them at risk for diminished quality of life and at risk for burn injuries. Findings Included: Record review of Resident #157's , electronic face sheet dated 12/04/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified Dementia, Mixed Receptive Expressive Language Disorder (problems with speaking), Muscle wasting and Atrophy (loss of muscle tissue), Hyperlipidemia (high cholesterol), and Polyosteoarthritis (arthritis that affects five or more joints at the same time). Record review of Resident #157's comprehensive MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #161) of 8 residents reviewed for care plan completion. The facility failed to complete a baseline care plan that addressed enhanced barrier precautions for Resident #161 within the required 48-hour timeframe of admission. This deficient practice could place newly admitted residents at risk of not being provided with the necessary care and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #161's face sheet dated 12/02/2024 revealed the resident was an [AGE] year-old male admitted on [DATE] with the following diagnoses: Urinary tract infection- ESBL(bacteria resistant to most antibiotics), Metabolic Encephalopathy (a disorder that affects brain function),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store all drugs and biologicals in a locked compartment under proper temperature controls and permit only authorized personnel to have access to the keys for one (Resident #53) of seven residents reviewed for medications. Resident #53 had an unidentified medicated cream in a small plastic cup sitting on his nightstand. This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication. The findings were: Record review of Resident #53's admission Record dated 12/02/24 revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of acute kidney failure with medullary necrosis (a severe condition where the kidneys suddenly lose their ability to filter waste products from the blood, specifically caused by damage and cell death in the inner part of the kidney), essential (primary) hypertension (high blood pressure that has no identifiable cause), other specified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standard or food service safety for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure all food items were labeled and dated in the refrigerators and in the dry storage. This failure could place residents at risk of foodborne illnesses. The findings included: An observation and interview during the initial tour of the facility's #2 refrigerator on 12/02/24 at 8:53 a.m. revealed on opened one gallon container of Dijon honey mustard salad dressing with the dates of 04/23 and 05/17 on the lid. The Dietary Manager said they do not use the Dijon dressing that often. An observation of the facility's #1 refrigerator on 12/02/24 at 8:54 a.m. revealed a 17 oz container of Siracha hot chili sauce without a date. An observation of the facility's dry storage on 12/02/24 at 8:56 a.m. revealed six loaves of bread that were not dated. In 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 interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 3 residents (Resident #2) reviewed for abuse/neglect. The facility failed to report Resident #2's unwitnessed fall with injury on 01/04/24, where Resident #2 sustained a 4 cm laceration to the back of her head that would not stop bleeding and sent out to the hospital. State Survey Agency was not notified of the fall with injury within 2 hours. The incident occurred on 01/04/24 at 7:30 a.m. and was not reported. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect. The findings included: Record review of Resident #2's admission Record dated 11/07/24, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or resident representative written notice which specified the duration of the bed-hold policy at the time of transfer of a resident for hospitalization for 1 of 3 residents (Resident #1) reviewed for transfers, in that: The facility did not ensure Resident #1's RP was provided with a written bed-hold policy on 11-06-2023 when Resident #1 was transferred to the hospital. This failure could place residents at risk of being improperly discharged and placed in unsafe conditions. The findings included: Record review of Resident #1's face sheet dated 11/12/2024 reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), seizers (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 3 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report Resident #1's unwitnessed fall with injury where Resident #1 sustained a 6 cm laceration to the left side of her eyebrow which required 12 stitches to close to State Survey Agency within 24 hours. The incident occurred on 05/10/2024 at 5:34 p.m. The facility emailed the report on 05/13/2024. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect. The findings included: Record review of Resident #1's admission Record dated 10/10/24, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included: Dementia (a general term for a group…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours 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 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect. The facility failed to report allegations of resident neglect for Resident #1 to the State Survey Agency within the allotted time frame of 2 hours on 08/07/24 when Resident #1 had a fall at around 5AM and sustained a serious bodily injury (laceration to her head), which required 22 sutures/staples. This failure could place all residents at increased risk for potential neglect due to unreported allegations of abuse and neglect. The findings included: Record review of Resident #1 's file dated 08/19/24 reflected…

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, interviews and record review the facility failed to have physician orders for the residents immediate care at time of admission for 1 of 4 residents (Resident #3) reviewed for physician admission orders. The facility failed to have physician orders in place for care/treatment/monitoring of Resident #3's colostomy. This deficient practice could place residents with a colostomy at risk in delay in treatment/care. The findings were: Record review of Resident #3's face sheet, dated 08/05/24, revealed a [AGE] year old male with an initial admission date of 10/13/2023 with diagnoses which included: encounter for surgical aftercare following surgery of the digestive system (organs that are important for digesting food and liquids), acquired absence of other specified parts of digestive tract (made up of organs that food/liquid travel through when they are swallowed, digested, absorbed and leave the body as feces), colostomy (surgery to create an opening for the colon through the belly) status,…

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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 Residents (Resident #3) reviewed for medical records accuracy, in that: Resident #3's skin assessment documentation was incomplete. Staff did not document Resident #3's surgical incision. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: Record review of Resident #3's face sheet, dated 08/05/24, revealed a [AGE] year old male with an initial admission date of 10/13/2023 with diagnoses which included: encounter for surgical aftercare following surgery of the digestive system (organs that are important for digesting food and liquids), acquired absence of other specified parts of digestive tract (made up of organs that food/liquid travel through when they are swallowed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 Residents (Resident #2) reviewed for medical records accuracy, in that: Resident #2's April and May 2024 Treatment Administration Records documentation was incomplete. Staff did not document or sign off on the administration of physician ordered wound care. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: 1. Record review of Resident #2's face sheet, dated 06/13/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: pressure ulcer of sacral region, stage 4 (sores that extend below the subcutaneous fat into deep tissue, including muscle, tendons and ligaments), Alzheimer's disease, unspecified (progressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment, to particpate or in experimental research, and to formulate an advance directive for 4 (Resident #37, Resident #40, Resident #20, Resident #58) of 14 residents whose records were reviewed for Out-of-Hospital Do-Not-Resuscitate Order forms in that: 1. The facility did not ensure Resident #40's OOH-DNR form was completed fully and correctly. 2. The facility did not ensure Resident #37's OOH-DNR form was completed fully and correctly. 3. Resident #20 had missing information on the front of their OOHDNR ((Out of Hospital Do Not Resuscitate) form. 4. Resident #58 had missing information on the front of their OOHDNR (Out of Hospital Do Not Resuscitate) form. These failures could affect the 18 residents in the facility with OOHDNR orders at risk of CPR performed against their wishes. The findings included: 1.Record review of Resident #37's Face Sheet dated [DATE] indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures to investigate any such allegations, for 1 of 3 residents (R #1) reviewed for incidents/accidents. The facility failed to follow the incidents/accidents policy for an incident on 07/30/23 for R #1. This failure could place residents at risk of further incidents. The findings included: Record review of the Policy: Incidents and Accidents Policy (date implemented: 08/15/22) Compliance Guidelines: 2. Licensed staff will utilize PCC Risk Management to report incidents/accidents and assist with completion of any investigative information to identify root causes. 12. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions. Record review of R #1's file reflected an [AGE] year-old female, with an original admission date of 10/11/19. Her diagnoses included: Dementia, Osteoarthritis, muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop the resident's comprehensive care plan for two (Resident #40, Resident #44) of 14 residents reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that: 1. The facility failed to develop a care plan to address Resident #40's choice of Do not Resuscitate code status. 2. The facility failed to implement a comprehensive person-centered care plan for Resident #44 addressing 1/4 side rails to bed. This failure could affect the 18 residents in the facility who chose to formulate advance directives of OOH-DNR at risk of having CPR performed against their wishes and could place resident in the facility at risk for decrease level of function with ADLs, falls and not having personalized plans developed to address their needs. The findings included: 1.Record review of Resident #40's Face Sheet dated [DATE] indicated Resident #40 was 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 the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 14 residents ( Resident #58), reviewed for comprehensive care plans in that: Advanced directive code status was not updated for Resident #58 care plan. These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care. The findings included: Record review of Resident # 58's face sheet dated [DATE] revealed resident was admitted on [DATE] with diagnosis that included osteoarthritis, right knee, history of falling, type 2 diabetes mellitus, chronic kidney disease, hypertension, dementia, psychotic disturbance, atrial fibrillation, moderate protein-calorie malnutrition, transient ischemic attack (TIA), cognitive communication deficit. Record review of Resident #58's MDS dated [DATE] revealed a 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.

Based on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident noted in 3 of 6 medication carts (Medication cart A) reviewed. Medication cart A contained 1 prescription medication card containing Hydralazine 10mg for Resident #15 that was expired 08/31/2023. The deficient practice could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: During medication pass observation on 09/19/2023 at 03:11PM MA A, was not going to administer Hydralazine 10mg to Resident#15 due to blood pressure reading being out of parameters. Noted Hydralazine 10mg medication card had an expiration date of 8/31/2023. MA G proceeded to take it and show it to RN J who stated that it was probably a pharmacy error. RN J then notified DON and she instructed him to call pharmacy. MA G stated the last time it was administered 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 observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (CNA) observation for infection control. The facility failed to ensure CNA E performed proper peri-care (incontinent care) for Resident #14. This deficient practice could place resident in the facility at risk for infections due to improper incontinent care. Findings included: Observation on 09/19/2023 at 1:28 PM, CNA E performed incontinent care for Resident #14, did not clean the buttocks/anal area. An interview on 09/19/2023 with CNA E at 1:56 PM, stated she has not done catheter care in a while. Surveyor asked why she did not clean buttocks/anal area. She said she completely forgot because she was probably concentrating on doing catheter care correctly. Stated she normally does clean the buttocks/anal area. 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.