Huebner Creek Health & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to within 14 days after a facility completes a resident's assessment to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 1 resident (Resident #89) reviewed for MDS transmission. Resident #89's discharge MDS assessment was not transmitted within 14 days of completion. This deficient practice placed residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Review Resident #89 face sheet, dated 03/11/2026, revealed and admission date of 09/25/2026 with diagnoses which included: acute kidney failure, unspecified, urinary tract infection, site not specified, essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus with diabetic chronic kidney disease, and hypo-osmolality and hyponatremia. Review of Resident #89's Discharge MDS Assessment, dated 10/11/2025, revealed the assessment had not been transmitted to CMS. During an interview and observation on 03/11/2026 at 1:35 p.m. the MDS Case Manager stated 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #6) reviewed for care plans: The facility failed to ensure Resident #6's comprehensive care plan included he received dialysis services outside the facility. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.The findings included: Record review of Resident #6's admission record, dated 3/11/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of dementia (a progressive neurological disorder that affects memory, thinking, behavior, and the ability 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 provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 2 of 8 Residents (Resident #45 and Resident #80) reviewed for quality of life. 1. The facility failed to ensure Resident #45 received scheduled showers on 3/3/26 and 3/7/26. 2. The facility failed to ensure Resident #80 received scheduled showers on 3/3/26, 3/5/26, and 3/10/26. This deficient practice could affect any resident and contribute to feelings of poor self-esteem and hopelessness.The findings included:1. Record review of Resident #45's admission record, dated 3/11/26, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis or weakness on one side of the body resulting from a stroke), seizures(sudden, uncontrolled electrical disturbances in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 residents (Resident #64) reviewed for quality of care. The facility failed to ensure Resident #64's sterile water was dated on the oxygen concentrator. This failure could place residents at risk for infection. The findings include: Record review of Resident #64's face sheet, dated 3/9/2026, revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 5/30/2023, with a primary diagnosis of spinal stenosis, lumbar region with neurogenic claudication (narrowing of spinal canal compresses nerves causing leg pain, numbness, or weakness). Record review of Resident #64's MDS assessment, dated 2/13/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact. Record review of…

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 residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #6) reviewed for quality of care: The facility did not maintain communication, coordination, or collaboration with the dialysis facility for Resident #6. This failure could affect residents who received dialysis treatments and place them at risk of complications and not receiving proper care and treatment to meet their needs. The findings included:Record review of Resident #6's admission record, dated 3/11/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of dementia (a progressive neurological disorder that affects memory, thinking, behavior, and the ability to perform daily activities), type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood glucose levels due to insulin resistance and/or decreased insulin production), and end…

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 its medication error rate was not 5 percent or greater. The facility had a medication error rate of 5.88% based on 2 out of 34 opportunities, which involved 2 of 6 Residents (Resident #6 and Resident #8) reviewed for medication administration, in that: 1. The facility failed to ensure LVN I primed the insulin pen for Resident #6 prior to administration. 2. The facility failed to ensure LVN I primed the insulin pen for Resident #8 prior to administration. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.The findings included: 1. Record review of Resident #6's admission record, dated 3/11/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of dementia (a progressive neurological disorder that affects memory, thinking, behavior, and the ability to perform daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 nurses' medication carts (600 hall nursing medication cart) reviewed for storage of drugs. The facility failed to ensure the 600-hall nursing medication cart was locked. This deficient practice could place residents at risk of medication misuse and diversion.The findings were: Record review of Resident #99's admission record, dated 3/11/26, revealed a [AGE] year-old female resident originally admitted on [DATE], and readmitted on [DATE] with diagnoses including aphasia following cerebral infarction (a communication disorder caused by brain damage from a stroke that affects the ability to speak or understand language), cerebral palsy (a group of disorders affecting movement, muscle tone, and posture caused by damage to the developing brain), bipolar disorder (a mental health disorder characterized by alternating episodes of depression and mania or elevated mood),…

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 dispose of garbage and refuse properly for 1 of 1 trash disposals areas that were reviewed for disposal of garbage. The facility failed to ensure trash was not left outside of the trash disposal container. This failure could place residents at risk for rodent infestation.The findings include: During an observation on 3/8/2026 at 10:05 a.m., 1 bag of trash was leaning against the trash disposal container that was located outside the facility in a gated area. During an interview on 3/8/2026 at 10:08 a.m., the DM stated the trash area falls under her and that it should look clean, nothing on the floor and the doors closed. The DM stated the purpose of that is to prevent rodents and for infection control. Record review of the facility's policy Waste Control and Disposal, dated 2012, stated:3.Trash must be securely tied in leak-proof plastic bags and removed from the department to the outdoor trash receptacle.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure LPN A cleaned the blood pressure cuff between Resident #1 and Resident #2 on 02/13/2026. These deficient practices could place residents at-risk for infections.The findings included: During an observation on 02/13/2026 at 07:40 a.m., LPN A was observed taking Resident #1's blood pressure prior to administering medications to the resident. LPN A returned to her medication cart and placed the blood pressure cuff on the cart. LPN A did not sanitize the blood pressure cuff. LPN A then administered Resident #1 his medications. At 07:58 a.m., LPN A then went and took Resident #2's blood pressure with the same cuff. LPN A again returned to her medication…

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 for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to write a discard date on ham and cheese in the walk-in refrigerator.The facility failed to ensure foods were stored at least 18 inches from the ceiling. The facility failed to ensure that bacon was covered in the walk-in refrigerator. The facility failed to ensure [NAME] C wore a beard restraint while cooking for 01/13/26 dinner. These failures could place residents at risk for food borne illness. The findings included: Observation and interview on 01/13/26 at 04:16PM revealed there was a package of ham and a package of cheese in the walk-in cooler that did not have discard dates. The CDM revealed when the ham and cheese were opened, they had 14 days until they had to throw it out. It was observed that there were boxes in the walk-in refrigerator and walk-in freezer that were less than 18 inches from the ceiling. The CDM revealed she was in charge of putting…

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 assessment accurately reflected the resident's status for 2 of 5 residents (Resident #1 and #2) reviewed for assessments. 1. Resident #1's admission MDS, dated [DATE], was coded No regarding the resident had a pressure ulcer. Resident #1 had a pressure ulcer to her right buttock. 2. Resident #2's Medicare-5 days MDS, dated [DATE], was coded No regarding the resident had an indwelling urinary catheter. Resident #2 had an indwelling urinary catheter. These failures could place residents at risk for inadequate care due to inaccurate assessments.The findings included: 1. Record review of Resident #1's face sheet, dated 01/15/2026, revealed the resident was [AGE] years old female, originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of intracerebral hemorrhage (sudden bleeding into the tissues of the brain), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), 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 observations, interviews, 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 1 (Resident #3) of 3 residents reviewed for incontinence care. On 01/14/2026, CNA-B did not clean Resident #3's suprapubic area (region of the abdomen located below the umbilical region) and did not open the resident's labia area. This failure could place residents who require incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.The findings included: Record review of Resident #3's face sheet, dated 01/15/2026, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnoses of fracture of neck of left femur (hip fracture), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), and dementia (over time destroy nerve…

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 activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of 3 (Resident #2, 3, 4) out of 12 who were reviewed for activities. The facility failed to consistently provide individualized activities and did not meet the needs of the Resident #2, #3, and #4, especially nights and weekends. These failures placed the residents at risk of becoming apathetic (marked indifference to the environment), isolated from others, having a depressed mood, boredom, loneliness, and a decreased quality of life. Findings included: Record review of Resident #4's admission record, dated 10/21/25, reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include depression. Record review of Resident #4's quarterly MDS assessment, dated 09/01/25, reflected Resident #3 had a BIMS of 15 out of 15, indicating intact…

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 had the right to reside and receive 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 1 of 6 (Resident # 1) reviewed for call light. The facility failed to ensure Resident # 1's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being. Findings include: Record review of Resident # 1's face sheet dated 10/22/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident # 1had a diagnosis that included: Quadriplegia (a condition characterized by paralysis or severe weakness in all four limbs), Muscle wasting and atrophy (refers to the loss of body mass and strength), and Acute respiratory failure (a life-threatening condition where the lungs cannot exchange oxygen and carbon dioxide). 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 interview and record review the facility failed to ensure each resident had the right to observe resident's religious beliefs in the facility that were significant to the resident for one (Resident #5) of twelve residents reviewed for self-determination. The facility failed to promote Resident #5's self-determination by not honoring his choice to practice his religion. This failure could place residents at risk for poor self-esteem and decreased self-worth due to their needs and preferences not being met. Findings included:Record review of Resident #5's admission record, dated 10/23/25, reflected an [AGE] year-old male initially admitted [DATE] and re-admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), need for assistance with personal care, and depression. Record review of Resident #5's quarterly MDS assessment, dated 09/09/25, reflected Resident #5 had a BIMS of 9 out of 15, indicating moderate cognitive impairment. 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 12 residents (Residents #2 and #5) reviewed for care plans, in that. 1. The facility failed to update Resident #5's care plan to reflect his religion. 2. The facility failed to update Resident #2's care plan to reflect his diagnosis of PTSD. This failure could place residents at risk of not receiving appropriate care. The findings included: Record review of Resident #5's admission record, dated 10/23/25, reflected an [AGE] year-old male initially admitted…

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 reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for clinical records. The facility failed to ensure Resident #1's wound care treatments were accurately documented on his Wound Administration Record (WAR) for 3 (06/14/2025 *Ev, 06/15/2025 Day, and 06/15/2025 *Ev) of 39 treatments scheduled between the day shift of 06/01/2025 through the day shift of 06/20/2025 reviewed. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included: Record review of Resident #1's admission Record, dated 06/24/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #1's Diagnosis Report, dated 06/24/2025, reflected a primary diagnosis of acute…

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 maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for 1 (CNA F) of 5 staff observed for infection control. CNA F failed to perform hand hygiene while serving and assisting residents with their meal on 06/26/2025. These deficient practices placed residents at risk for cross contamination and spread of infection. Findings included: During an observation in the facility 700-hall and facility dining room on 06/26/2025 at 12:06 p.m., CNA F was observed to have left a resident room after delivering a meal tray. She took off and adjusted her eyeglasses, put her glasses back on, grabbed another resident's meal tray, and walked down the hall toward the facility dining room while holding the resident lunch tray. In-route she adjusted her eyeglasses a second time with one hand, placed the meal tray on the table in-front of a resident, sat down, picked up the resident's meal utensils, and while holding the resident's utensils…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Residents #3) reviewed for infection control: The facility failed to ensure CNA A utilized hand hygiene between glove changes during peri-care on Resident #3. This failure could place residents at-risk for infection due to lack of hand hygiene and could result in infection or illness. The findings included: Record review of Resident #3's face sheet dated 4/10/2025 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: type 2 diabetes mellitus with diabetic neuropathy, acute on chronic systolic (congestive) heart failure, and generalized muscle weakness. Record review of Resident #3's annual MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated she was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 2 (Residents #39 and #43's) of 20 resident rooms reviewed for environment, in that: 1. A strong urine odor was coming from from Resident #39's room, and there were urine and feces found on his sheets. 2. The toilet in Resident #43's restroom was loose and wobbled when Resident #43 used the toilet. These failures could result in resident injury and psychosocial harm due to diminished quality of life. The findings were: 1. Record review of Resident #39's face sheet dated 01/12/2025 revealed he was an [AGE] year old man who had an admission date of 05/01/2021, with diagnoses which included: Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities); Overactive bladder (a problem with bladder function that causes the sudden need to urinate); Hearing Loss and Need for assistance with personal care. Record 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 interview and record review, the facility failed to develop a baseline care plan which included the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 2 (Residents #12 and #29) of 8 residents reviewed:: 1) Resident #12's baseline care plan was not completed within 48 hours of admission. 2) Resident #29's baseline care plan was not completed within 48 hours of admission. This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services. The findings were: 1)Record review of Resident #12's face sheet, dated 01/13/2025, revealed she was an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses which included: Dementia (a general term for loss of memory, language, and other cognitive abilities); Dehydration (a dangerous loss of body fluid caused by illness, sweating or inadequate fluid intake); Chronic Respiratory Failure with Hypoxia (condition where lungs are unable…

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 comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #12) reviewed for care plans. Resident #12's diagnoses of Depression, Generalized Anxiety Disorder and Dementia, along with active orders for anti-anxiety and anti-psychotic medications were not addressed in her comprehensive care plan This failure could affect residents who have care areas not addressed by the care plans by not having their needs met and putting them at risk of not receiving…

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 review and revise resident care plans after each assessment for 1 of 8 residents (Resident #39) reviewed for care plan revision/timing. The facility failed to ensure Resident #39's care plan was revised to reflect 3 falls in a 4-hour time period. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health. Findings included: Record review of Resident #39's face sheet dated 01/12/2025 revealed he was an [AGE] year old man, who as admitted to the facility on [DATE], with diagnoses which included: Dementia (a general term for loss of memory, language, and other cognitive abilities); Overactive Bladder (a problem with bladder function which causes sudden needs to urinate); Hearing Loss and Unsteadiness on Feet. Record review of Resident #39's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 08, indicating moderate cognitive impairment. 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 ensure residents receive treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 2 residents (Resident #37) reviewed for wound care. The facility failed to ensure wound dressings and leg wrapping were applied daily for Resident #37. This failure could place residents at risk of pain and lead to systemic infections. Findings included: Record review of Resident #37's face sheet dated 01/13/2025 revealed the resident was a [AGE] year-old woman who was admitted to the facility on [DATE] with diagnoses which included: Lichen Simplex Chronicus (skin condition that causes chronic itching); Obesity (chronic complex disease defined by excessive fat deposits that can impair health); difficulty in walking and need for assistance with personal care. Review of Resident #37's quarterly MDS assessment dated [DATE],…

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 locked compartments for the only medication room and one of seven nurse medication carts (Hall 500 nurse medication cart) observed for drug storage and usage, as evidenced by: 1. The facility failed to ensure the controlled medication compartment inside the refrigerator of the medication room was locked. 2. The facility failed to ensure three medications for Resident #54 were stored and locked inside the Hall 500 medication cart. These failures could place residents at risk of misappropriation of medication, ingesting medications not prescribed or drug diversion. The findings included: 1. During an observation on 01/14/25 at 10:00 AM of the medication storage room with the DON and LVN D, it was observed that the affixed bin inside the refrigerator for storing controlled substances was unlocked and contained the controlled medication lorazepam. During an interview with the DON on 01/14/25 at 10:05 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.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 (CNA G, LVN H, LVN I, LVN J and PT) of 25 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to CNA G, LVN H, LVN I, LVN J, and PT annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings included: Record review of personnel records for CNA G revealed a hire date of 3/21/2018. Further review of a training log, provided by the HR Manager revealed no evidence of annual training for Resident Rights, Dementia, Behavioral Health, HIV, Falls, Restraints and Emergency Preparedness. Record review of personnel records for LVN H revealed a hire date of 6/21/2016. Further review of a training log, provided by the HR Manager revealed no evidence of annual training for Resident Rights, Dementia, QAPI, Ethics, Behavioral Health, HIV, Restraints, Emergency Preparedness Record review of personnel records for LVN I…

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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation 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 (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 8 residents (Residents #1) reviewed for reporting allegations of abuse, neglect, and exploitation. The facility failed to report an allegation of neglect to the state agency when on 02/24/2024 Resident #1 was assessed…

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 allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action were taken, for 1 of 8 residents (Residents #1) reviewed for allegations of abuse, neglect, and exploitation. The facility failed to investigate and report an allegation of neglect when on 02/24/2024 Resident #1 was assessed by RN A as lethargic and difficult to arouse with a Tylenol bottle at the bedside. RN A called 911 and EMS transported Resident #1 to the emergency room for evaluation 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 interviews and record reviews the facility failed to record in residents' medical records sufficient information to identify the Resident and services provided, for 1 of 8 residents (Residents #2) reviewed for services provided with documentation of nursing services. LVN LL failed to document her skin assessment, report to the physician and Resident's Representative, and detailed physicians order when on 10/23/2024 LVN LL assessed Resident #2 with a rash, communicated with the physician, and the physician prescribed Resident #2 a steroid skin cream. This failure could place residents at risk for inaccurate medical records. The findings included: A record review of Resident #2's admission record revealed an admission date of 06/28/2024 and a discharge date of 10/25/2024 with diagnoses which included hemiplegia and hemiparesis following cerebral infarction, restlessness and agitation, and cognitive communication deficit. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed…

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 personal privacy for 3 of 6 (Resident #2, Resident #4, and Resident #6) reviewed for dignity. 1. The facility failed to ensure Resident #2 was provided with privacy during wound care. 2. The facility failed to ensure Resident #4 was provided with privacy during wound care. 3. The facility failed to ensure Resident #6 was provided with privacy during ADLs. These failures could affect residents by contributing to poor self-esteem, decreased self-worth, and quality of life. Findings included: 1. Record review of Resident #2's admission Record, dated 11/13/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic ischemic heart disease (heart's blood supply is reduced over time), muscle wasting, malnutrition, hyperlipidemia (high levels of fat in the blood), depression (low mood), anxiety (feeling of dread, fear, or uneasiness), hypertension (high blood pressure), chronic obstructive…

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 resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 3 of 4 residents (Residents #1, Resident #3, and Resident#4) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's treatments were documented per facility policy. 2. The facility failed to ensure Resident #3's treatments were documented per facility policy. 3. The facility failed to ensure Resident #4's treatments were documented per facility policy. These deficient practices could place residents at risk for improper care due to inaccurate records. The findings were: 1. Record review of Resident #1's admission Record, dated 11/13/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: sepsis (life-threatening complication of an infection), acute kidney injury…

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 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 5 of 6 residents (Resident #1, Resident #2, Resident #4, Resident #5, and Resident #6) reviewed for infection control. 1. The facility failed to use proper infection control practices during wound care and perineal care for Resident #1. 2. The facility failed to use proper infection control practices during wound care for Resident #2. 3. The facility failed to use proper infection control practices during wound care for Resident #4. 4. The facility failed to use proper infection control practices during toileting for Resident #5. 5. The facility failed to use proper infection control practices during hygiene, dressing, and linen change for Resident #6. 6. The facility failed to ensure staff complied with Enhanced Barrier…

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 reviews the facility failed to protect and facilitate resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to a telephone for 1 of 1 facility's phone system reviewed for operation. The facility did not provide a staff member to monitor the facility secured entrance to allow visitors and providers access to residents and only provided a signage with the facility's phone number; however, the phone at the nurse station was unable to ring and alert anyone of an incoming call. This failure could place residents at risk for denying access to the residents to include a physician and or family. The findings included: During an observation on 10/12/2024 at 10:15 AM revealed the facility's main entrance glass door to be secured, there was no doorbell and there was a small sign with the facility's phone number with direction to call for assistance. Observation through the glass door revealed a reception hallway with a receptionist desk and office doors. Continued observation…

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 be adequately equipped to allow Residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 2 of 6 residents (Residents #2 and #4) reviewed for a nurse call system. 1. Resident #4 was placed in his room on 10/12/2024, without a call light system in place for Resident #4 to alert staff for assistance and or emergencies. 2. Resident #2 used his call light on 10/12/2024 to alert staff however Resident #2's call light system was inoperable due to a malfunctioning illuminator outside of his room. Resident #2 did not receive assistance for 36 minutes until the surveyor intervened and alerted staff Resident #2 needed assistance. These failures could place residents at risk for harm by residents' inability to call for help and staff's inability to respond to residents who ask for assistance. Findings included: 1.…

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, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible for 9 of 25 residents (Residents #4, #30, #48, #49, #18, #25, #256, #20, #29) reviewed for homelike environment, in that: 1. Residents #4, #30, #48, and #49 did not have a nightstand for their personal use in their rooms. 2. Residents #18, #25, and #256 did not have their personal televisions or televisions that worked in their rooms for use. 3. Resident #29 and #20 did not have a television in their rooms. These failures could place residents at-risk for not having a setting to store personal items, and use of their personal belongings in a homelike environment and could result in feelings of frustration, loss of independence, and a decreased quality of life. The findings were: 1. Record review of Resident #4's face sheet, dated 12/03/23, revealed a [AGE] year old male with an admission date of…

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 residents who were unable to carry out activities of daily living the necessary services to maintain good personal hygiene to dependent residents for 3 of 3 residents (Resident #20, #27, #29) reviewed for ADL care: 1. Resident #20 had long nails and were not trimmed. 2. Resident #27 had long nails and were not trimmed. 3. Resident #29 was not able to shave himself for 2-3 days due to shaver in his old room. This could affect all residents who require assistance personal hygiene and it could contribute to poor hygiene and dignity. The Findings were: 1. Record review of Resident #20's admission Record dated 12/6/2023 revealed he was admitted on [DATE] with diagnoses of hearing loss, spinal stenosis (narrowing of the spinal canal which causes pressure on your spinal cord or the nerves that go from your spinal cord to your muscles), anxiety disorder, left and right leg above the knee amputation and need for assistance of personal 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment that included hand hygiene procedures to be followed by staff involved in direct resident contact for 1 of 3 halls (700 hall) reviewed for hand hygiene, in that: The 700-hall had no hand sanitizer in the wall units and rooms [ROOM NUMBER] had no paper towels. This failure could place residents at risk of cross contamination, illness, and infection. The findings were: Observation on 12/3/23 at 9:40 a.m. revealed on 700-hall on the walls in the hallway were large gray sanitizer dispensers that were not functional. The push handles to dispense the hand sanitizer were recessed against the dispenser and were unusable. Observation on 12/3/23 at 9:41 a.m. revealed in room [ROOM NUMBER] there were no paper towels observed in the bathroom. Observation on 12/3/23 at 9:55 a.m. revealed CNA B was observed answering call lights and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the residents right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #6) reviewed for accommodation of needs, in that: Resident #6's toilet and air conditioner were not working properly. This deficient practice could impact residents ADL's, create feelings of frustration and worthlessness, and could result in a decreased quality of life. The findings were: Record review of Resident #6's face sheet dated 12/6/23 revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis lumbar region with neurogenic claudication (narrowing of the lumbar spine putting pressure on the spinal cord and nerve roots causing pain, heaviness and weakness to the legs), type 2 diabetes with neuropathy (chronic condition that affects the way the body processes blood…

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 was incontinent of bladder received appropriate treatment and services for 1 of 1 resident (Resident #20) reviewed for Indwelling urinary catheters in that: Resident #20's indwelling catheter bag was in a basin and the basin had liquid in it. This could affect all residents with an indwelling catheter and could place them at risk for cross contamination and urinary tract infections. The Findings: Record review of Resident #20's admission Record dated 12/6/2023 revealed he was admitted on [DATE] with diagnoses neuromuscular dysfunction of bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem) and need for assistance of personal care. Record review of Resident #20's Quarterly MDS dated [DATE] revealed for Cognition he was 11/15 (moderately impaired), he had an indwelling catheter, upper body dressing and required maximum assistance…

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, based on a resident's comprehensive assessment, ensure that a resident was offered sufficient fluid intake to maintain proper hydration and health for 1 of 6 residents (Resident #26) reviewed for hydration, in that: Resident #26 was not given water when requested for his dry mouth and throat. This failure could place residents at risk of not receiving proper hydration and could result in feelings of frustration, worthlessness, and a decreased quality of life. The findings were: Record review of Resident #26's face sheet dated 12/4/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. Diagnoses included other sequelae following unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain with residual effects or conditions produced after the acute phase of an illness or injury has ended), contractures to right and left hands…

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 needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 (Resident #31) resident with a tracheotomy in that: Resident #31 had a trach with no AMBU device and the trach collar and plastic over it were dirty with hair. This could affect all resident with tracheostomy and could result in loss of oxygen and infections. The Findings were: Record review of Resident # 31's admission Record dated 9/14/2023, age was 30, revealed she was admitted on [DATE], re-admitted on [DATE] with diagnoses of traumatic cerebral edema (swelling that occurs in the brain) with loss of consciousness of 24 hours, quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), gastrostomy, tracheostomy (an incision in the…

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

Based on observation, interview, and record review the facility failed to post nurse staffing data on a daily basis over two 24 hour time periods for 1 of 1 facility in that, The nurse staffing data was not posted for the dates of 12/03/23 and 12/04/23. This deficient practice could place residents at risk by not providing adequate staffing information for the staff and the general public to ensure that resident care needs are met. The findings include: Observation on 12/03/23 at 10:00 a.m., in front of the nurses station revealed nursing staffing information was not posted. Observation on 12/4/23 at 2:45p.m., in front of the nurses station revealed nursing staffing information was not posted. Interview with Clerical Staff-G on 12/3/23 at 1030 a.m., revealed that she had the nursing staffing posting information on top of her desk inside of her cubicle. She stated that it had been taken down due to reconstruction activity inside the facility. Interview with Clerical Staff-G on 12/4/23 at 2:50 p.m., revealed that she still had the nursing staffing posting information on top of her…

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 and the resident's representative/s of the discharge and the reasons for the move in writing and in a language and manner they understand and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman at least 30 days before the resident is transferred or discharged for 1 of 4 residents (Resident #1) reviewed for discharge, in that: The facility did not issue a written discharge notice, stating the reason for the transfer/discharge, the location to which the resident would be transferred, or the right of appeal., to Resident #1 at least 30 days prior to her discharge to the local hospital on 8/12/23. The facility did not send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. This deficient practice could place the residents who are transferred and discharged at risk of having their discharge rights violated. The findings were:…

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.