Park Valley Inn Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 of 23 residents (Resident #2 and Resident #42) reviewed for infection control. The facility failed to ensure LVN C followed proper infection control procedures after completing the wound care for Resident #2, removing biohazardous trash from Resident #2's room and did not sanitize her hands after removing gloves and before touching clean supplies on her treatment cart. The facility failed to ensure LVN D followed proper infection control procedures after completing blood sugar check for Resident #42, exiting Resident #42's room, using the same gloves to open nursing cart, removed the insulin storage box for multiple residents on 700 Hall, and withdrew insulin from vial for Resident #42, and walked back to Resident #42's room to administer his insulin without changing gloves and sanitizing hands. These…

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 immediately consult with the resident's physician and notify the resident representative when there was a change in residents health status for 1 of 1 resident (Resident #1) reviewed for notification of changes. LVN B failed to immediately notify Resident #1's physician and Resident # 1's RP when CNA A reported to him that resident had skin tears to right hand and right elbow. This failure could place residents at risk of injury, hospitalization, and/or decreased quality of life. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinsonism (A set of movement symptoms associated with Parkinson's disease (PD) and other disorders, Unspecified Dementia (Condition which involves memory loss, affecting thinking, and social abilities which interfere with their daily lives.), Atherosclerosis (is a hardening of your arteries from plaque building up) and Heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #1 & #2) of 16 residents reviewed for quality of care. The facility failed to ensure that the residents were cared for in a kind manner for Residents #1 and Residents #2 by walking away from the residents and not returning. The noncompliance was identified as PNC. The noncompliance began on 09/10/25 and ended on 09/17/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving necessary care. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old woman who admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of cerebral infarction (a condition where blood flow to the brain was interrupted, leading to brain cell damage or death) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the residents were free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for one of six residents (Resident #1) reviewed for abuse.The facility failed to ensure Resident #1 was free from abuse when Resident #2 physically assaulted her on 09/27/25.The noncompliance was identified as PNC. The noncompliance began on 09/27/25 and ended on 09/30/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse.Findings included:Record review of Resident #1's face sheet dated 10/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, lack of coordination, muscle weakness,…

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 develop and implement a comprehensives person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of four residents reviewed for care plans. The facility failed to ensure Resident #1's care plan intervention for needing assistance with eating was implemented on 08/06/25. This failure could place residents at risk of not receiving the appropriate care to meet their needs. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility from 08/05/25 - 08/06/25 with a diagnosis including fractures of nasal bone and his vertebra (spine). Review of Resident #1's EMR, on 08/09/25, reflected an admission MDS assessment had not been completed. Review of Resident #1's initial care plan, dated 08/05/25, reflected he had an ADL self-care performance deficit with 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 develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 5 of 7 residents (Resident's #2, #3, #4, #5, and #6) reviewed for care plans. 1. The facility failed to ensure that Resident #2's care plan was revised, updated, and individualized to address Resident #2's risk for dehydration. 2. The facility failed to ensure care plan interventions (1:1 and/or in room activities) were implemented and documented for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. These failures placed residents at risk of not receiving the appropriate care to meet their current needs. Findings included: 1. Review of Resident #2's face sheet, printed on 06/04/25, reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included unspecified dementia (decline impacting memory,…

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 prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. 1. The facility failed to ensure [NAME] I wore a hair restraint that full covered her hair on 01/14/2025 while preparing food. 2. The facility failed to ensure [NAME] I performed hand hygiene when preparing food on 01/14/2025. These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. Findings included: Observation on 01/14/2025 at 7:06 AM revealed [NAME] I wore surgical mask around neck and hair fell out from hair net. Further review revealed DA K not wearing mask. Observation on 01/14/2025 at 7:18 AM revealed NSS L in kitchen with no mask on. Observation on 01/14/2025 at 10:09 AM revealed [NAME] I wore glove with hole on left hand. [NAME] L had hair sticking out of restraint and continued to wear mask around neck while she prepped food. Observation on 01/14/2025 at…

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 accommodate the needs and preferences for 5 of 10 residents reviewed for accommodations. The facility failed to ensure that Residents #17, #39, #159, #80, and #94 had call lights in reach while lying in bed. This deficient practice could place residents at risk of injury, for not receiving timely care, and for not receiving nursing interventions. Findings Included: Resident #39 Record review of Resident #39's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic pain due to trauma, a contusion of head, wedge compression fracture 3rd lumbar vertebrae, rheumatoid arthritis, fracture of left femur and nasal bones, repeated falls, severe protein-calorie malnutrition, hypotension, and nausea. Record review of Resident #39's Quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating her cognition was intact. Further review of the MDS revealed Resident #39 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review , the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, which included measurable objectives and time frames to meet the resident's mental and psychosocial need for three (Resident #3, Resident #73, and Resident #97) of six residents reviewed for care plans. The facility failed to update Resident #97's activity preferences were not updated after the quarterly assessment. The facility failed to update Resident #73's dental status and activity preferences were not updated after the quarterly assessment. The facility failed to implement a comprehensive care plan for Resident #3 within 21 days of admission on [DATE]. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Review of Resident #73 face sheet revealed an [AGE] year-old female admitted on [DATE] with diagnosis of Alzheimer's disease (a 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 observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 31 residents (Resident #3, Resident #59, Resident #97, and Resident #15) reviewed for resident rights. 1. The facility failed to ensure Resident #3, Resident #59 and Resident #97 clothing were changed daily on (01/14/2025 through 01/17/2025). 2. The facility failed to ensure Resident #15's room was free of odors and cleaned daily or as needed on 01/14/2025. This failure placed all residents at risk for not receiving adequate care and diminished quality of life and embarrassment. Findings included: 1. Review of Resident #3 face sheet revealed an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss and a decline in thinking skills), unspecified dementia (a general term for dementia that doesn't have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the resident had a right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms and to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for Resident #2 whose care was reviewed. in that: Resident #2 was in a wheelchair against the nurse's desk and a table in the dining room with the wheels locked prevented her from getting out of the wheelchair. These deficient practices affected 1 resident and had the potential to affect other residents who may be placed in restraints by contributing to restricted movement, a decline in ADL's function, and psychological distress. The findings include: A Record review of Resident #2's face sheet, care plan, and MDS was completed. Resident #2 revealed a [AGE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure their written policies and procedures were implemented regarding prohibiting and preventing abuse and neglect for 1 (Resident #95) of 6 residents reviewed for developing and implemented abuse and neglect policies. LVN T failed to report that Resident #95 was slapped on the shoulder by Resident #97 and failed follow incident procedures after she received report of incident on 01/14/2025. This deficient practice could place residents at risk of continued abuse, injury, trauma, and psychosocial harm. Findings included: Review of Resident #95 face sheet revealed a [AGE] year-old man admitted on [DATE] with diagnoses of peripheral vascular dementia (a type of dementia that's caused by reduced blood flow to the brain), restlessness and agitation (feelings of inner tension and severe restlessness that can manifest in a variety of ways) and cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked). Review…

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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one (Resident #159) of eight residents reviewed for nutrition status maintenance. The facility failed to obtain consistent weights of Resident #159. The facility failed to update the care plan to reflect the needs of Resident #159 The facility failed to keep accurate record of Resident #159's food intake. This failure could place residents at risk of further weight loss, malnutrition, and decreased quality of life. Findings included: Record review of Resident #159's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included a fracture of right femur and orthopedic aftercare, hypertension, congestive heart failure, mild intermittent asthma, vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 5 residents (Resident #31 and Resident #35) reviewed for pharmaceutical services. The facility failed to remove discontinued controlled medications from the medication cart for Resident #31 and Resident #35. The facility failed to ensure proper reconciliation for drugs and investigate errors. This failure leaves residents vulnerable to medication errors. Resident #31 Record review of Resident #31's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end-stage Alzheimer's disease and receiving hospice services, dementia, metabolic encephalopathy (a brain disease that causes altered mental status), repeated falls, anxiety disorder, muscle weakness, pain, abnormality of gait and mobility, dyspnea…

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 residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed on 11/04/24 during breakfast time to protect Resident #1 from physical and emotional abuse by CNA B, who threw a cup on him with agitation. This failure could place residents at risk of serious injury and harm. Findings included: Record review of Resident #1's face sheet on 11/06/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were hypertension, abnormal weight loss, dementia, cognitive communication deficit, lack of coordination, age-related physical debility, muscle weakness, abnormalities of gait and mobility, anxiety disorder, schizophrenia, anemia, and pain. Record review on 10/16/24 of Resident #1's quarterly MDS assessment, dated 10/28/24 revealed a BIMS score of 05 indicating his cognition was severely impaired. Record review on 10/16/24 of Resident #1's care plan…

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 residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 4 residents (Residents #2 and Resident # 3) reviewed for quality of care. The facility failed to ensure Resident #2 and Resident #3's nebulizing mask and tubing, that were observed on 11/06/24, were not bagged for sanitation when not in use per the facility's policy. This failure could affect residents who received nebulizing treatment and place them at risk for respiratory infections. The findings included: Record review of Resident #2's face sheet on 11/06/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were hypertension, dementia, cognitive communication deficit, muscle weakness, heart failure, type 2 diabetes, cough, and seasonal allergic rhinitis (allergy). Record review on 10/16/24 of Resident #2's quarterly MDS assessment, dated 10/13/24 revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, for 1 (Resident #1) of 4 residents reviewed for resident rights, in that: The facility failed to include Resident #1's HSP (Hospice) services in Resident #1's care planning process . The facility held an IDT meeting between 03/22/24 and 06/24/24 to discuss Resident #1's behaviors and alternative placement and did not invite and include Resident #1's HSP in the meeting. This failure could place residents at risk of not receiving appropriate interventions, treatments, and care. Findings included: Record review of Resident #1's undated Patient Information revealed he was an [AGE] year-old male. Resident #1 also had a POA (FAM) and Hospice services. Record review of Resident #1's undated admission Information revealed he was admitted to the facility on [DATE], discharged on 05/13/24, and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 (Resident #1) of 4 residents reviewed for hospice services, in that: The facility failed to immediately notify Resident #1's HSP about Resident #1's increase in aggressive behaviors and interfering or not allowing staff to provide care to some female residents behaviors and a need to transfer Resident #1 from the facility to due his behaviors from 03/22/24 through 06/24/24. This failure could place residents at risk of not receiving appropriate interventions, treatments, and care. Findings included: Record review of Resident #1's undated Patient Information revealed he was an [AGE] year-old male. Resident #1 also had a POA…

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 interviews and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility for one (LVN A) of two infection preventionists reviewed. The facility did not have and infection preventionist who worked at least part-time at the facility from 01/01/24 through 01/21/24. This deficient practice could place residents at risk of cross contamination and infection. Findings included: Record review of LVN A's time sheet from 01/01/24 through 02/07/24 reflected she did not work any hours as the IP from 01/01/24 through 01/21/24. During an interview on 02/06/24 at 9:00 AM, the DON stated LVN A was the Infection Preventionist for the facility. She stated LVN A was working on the floor but was available for questions. During an interview on 02/06/24 at 10:06 AM, LVN A stated she started working at the facility on 09/01/23 and was hired as the staffing coordinator and IP. She stated she was supposed to work 20 hours per week as the IP. During an interview on 02/07/24 at 1:05 PM, LVN A stated that she 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.

Based on interview and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for one of one facilities reviewed for nursing services. The facility failed to designate a DON from August 2023 to December 2023. This failure placed all resident at risk of decreased supervision and oversight of nursing related services. Findings included: During an interview on 12/11/2023 at 9:18 a.m., the Administrator stated he started about a month ago and the previous DON left before he started working at the facility. The Administrator stated the new DON would start in about two and a half weeks. During an interview on 12/11/2023 at 4:17 p.m., RN A stated she was not the facility's interim DON. RN A stated the facility's last DON quit in August of 2023 and since then, she had been coming in to help one to two days a week. RN A stated the new DON started on 1/02/2023. During an interview on 12/12/2023 at 11:36 a.m., the RDCS stated between herself, RN A, and RN B, they provided management oversight. The RDCS stated RN C was the…

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

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for one of one kitchens reviewed for food and nutrition services. The facility failed to ensure all foods were stored off the floor, labeled, dated and discarded prior to their use-by date. These failures placed residents at risk of foodborne illness. Findings included: Observations of the kitchen's walk-in refrigerator on 12/11/2023 from 9:41 a.m. - 9:50 a.m. revealed the following: At 9:41 a.m., an opened jug of lemon juice without an opened date. At 9:42 a.m., an opened container or creamy Caesar dressing without a received date or an opened date. At 9:42 a.m., an opened container of buttermilk ranch without a received date or an opened date. At 9:43 a.m., an opened container of barbecue sauce without a received date or an opened date. At 9:44 a.m., an opened container of sweet pickle relish without a received date or an opened date. At 9:45 a.m., an opened package of honey ham inside a sealable bag without an opened date. At 9:46…

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, observation and record review, the facility failed to ensure call lights were in reach for 2 of 8 residents (Residents #25 and #29) for resident rights. The facility failed to ensure Resident #25 and Resident #29 had access to their call lights. This failure placed residents at risk for unmet needs. Findings included: Review of Resident #25's face sheet, undated, reflected a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with Hypoxia (below normal level oxygen), Pain, Diplegia (paralysis) of Upper Limbs, Need for Assistance with Personal Care and Repeated Falls. Review of Resident #25's MDS assessment, undated, reflected he had a BIMS of 11, which indicated moderate cognitive impairment . Section GG - Functional Limitation in Range of Motion indicated Impairment on both sides. Review of Resident #25's comprehensive care plan, undated, reflected he required total assistance from staff for eating, hygiene, toileting 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 report an allegation of abuse to the administrator of the facility and to the State Survey Agency for 2 of 2 (Resident #69 and Resident #203) residents reviewed for resident abuse. The facility failed to report an allegation of abuse to the State Survey Agency, received by LVN E on 10/13/2023, that Resident #203 hit Resident #69. This failure placed residents at risk for unidentified abuse. Findings included: A record review of Resident #69's face sheet dated 12/13/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (type of dementia), major depressive disorder (depression), generalized anxiety disorder, hypertension (high blood pressure), insomnia (sleep disorder), and muscle weakness. A record review of Resident #69's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. A record review of Resident #69's care plan dated 7/17/2023 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 have evidence that all alleged violations were thoroughly investigated for one of one allegations reviewed for resident abuse. The facility failed to ensure an allegation of abuse between Resident #69 and Resident #203 was thoroughly investigated. This failure placed residents at risk of unidentified abuse. Findings included: A record review of Resident #69's face sheet dated 12/13/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (type of dementia), major depressive disorder (depression), generalized anxiety disorder, hypertension (high blood pressure), insomnia (sleep disorder), and muscle weakness. A record review of Resident #69's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. A record review of Resident #69's care plan dated 7/17/2023 reflected she had Alzheimer's disease (type of dementia) and resided in the facility's memory 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 ensure residents' environment remained as free of accident hazards as possible for 1 of 8 (Resident #65) residents reviewed for quality of care. The facility failed to ensure Resident #65's did not possess an unsecured razor blade. This failure placed residents in the memory care unit at risk of injuries. Findings included: A record review of Resident #65's face sheet dated 12/13/2023 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of heart failure, unspecified dementia, cerebral infarction (stroke), hyperlipidemia (high cholesterol), hypertension (high blood pressure), and depression. A record review of Resident #65's admission MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. A record review of Resident #65's care plan dated 9/19//2023 reflected he had short-term memory impairment and was unable to recall after five minutes. During an observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide food that accommodates residents' preferences for one (Resident #29) of 8 residents reviewed for food and nutrition services. The facility failed to re-assess Resident #29's preferences after severe weight loss (16.123%) over the course of 6 months. This failure could place all residents at risk for severe weight loss and frustration from not enjoying meals. Findings include: Review of Resident #29's face sheet, undated, reflected an 81- year-old female who was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Abnormal Weight Loss, Nutritional Deficiency, Document Nutritional Status And Trouble Swallowing. Review of Resident #29's MDS assessment, undated, reflected she had a BIMS of 9 , which indicated moderate cognitive impairment. Section K - Weight Loss reflected Resident #29 was coded as a [2] for Loss of 5% more in the last month or loss of 10% or more in last 6 months. This indicated (per coding as…

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 to implement an effective discharge plan by not following their discharge planning policy and procedure for 1 of 2 residents reviewed (Resident #1) for discharge planning. The facility did not get the resident or representative a against medical advice form prior to the resident leaving the building per facility policy. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #1's face sheet, dated 9/23/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 9/20/2023. Resident #1 had medical diagnoses which included Parkinson's disease, ( a neurological disorder affecting movement) muscle weakness, adult failure to thrive, limitations of activities due to disability, functional urinary incontinence ( inability to get to the toilet in time due to disability ) and prediabetes ( high blood sugar. But not high enough for…

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