Parklane West Healthcare 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, functional, sanitary, and comfortable environment for residents, staff, and the public for 5 Resident's room (Resident #2, 3, 4, 5, 6) reviewed for environmental concerns. Water temperatures were less than 100 degrees Fahrenheit in Resident #2, 3, 4, 6's room. Water temperature was more than 110 degrees Fahrenheit in Resident #5's room. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings were: Record review of Resident #3's admission Record, dated 01/06/26, reflected an admission date of 04/25/25, with diagnoses that included weakness and need for personal assistance. Record review of Resident #3's Quarterly MDS assessment, dated 09/26/25, revealed a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #4's admission Record, dated 01/06/26, reflected an initial 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 interview and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 8 residents (Residents #1 and #2) reviewed for pharmacy services. On 01/06/25, Resident #1 received the following medications late: Apixaban Oral Tablet 2.5 MG, Polyethylene Glycol 3350 Powder, Thiamine HCl Oral Tablet 100 MG, Multivitamin-Minerals Oral Tablet, Megestrol Acetate Oral Suspension 40 MG/ML, levETIRAcetam Oral Solution 500MG/5ML, Ascorbic Acid Oral Tablet 500 MG, Metoprolol Tartrate Oral Tablet 25 MG, and Lidocan External Patch 5%. On 01/07/25, Resident #1 received the following medications late: Ascorbic Acid Oral Tablet 500 MG, Megestrol Acetate Oral Suspension 40 MG/ML, Polyethylene Glycol 3350 Powder, Thiamine HCl Oral Tablet 100 MG, levETIRAcetam Oral Solution 500MG/5ML, Multivitamin-Minerals Oral Tablet, Lidocan External Patch 5%, and Metoprolol Tartrate Oral Tablet 25 MG. On 01/08/25, Resident #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 ensure personal privacy for 1 of 2 residents (Resident #11) reviewed for privacy, in that: Resident #11 was observed in the hallway on 12/07/2025 with his foley bag attached to right calf without a privacy cover, exposing his foley bag contents to anyone in the hallway. This deficient practice could affect residents by resulting in loss of dignity and low self-esteem. The findings were: Record review of Resident #11's undated face sheet revealed Resident #11 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain), acute kidney failure (a condition where the kidneys stop working), Alzheimer's disease (a progressive disease that affects memory and other important mental functions) and legal blindness (a definition used to assess the severity of visual impairment). Record review of Resident #11's undated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented for 3 of 3 residents (Resident #1, Resident #2, Resident #3) reviewed during the complaint investigation. The facility failed to ensure that Resident #1's treatment administration record noted treatments on 9.6.2025, 9.20.2025, 10.2.2025, 10.25.2025 as required by the orders noted on the electronic medical record. The facility failed to ensure that Resident #2's treatment administration record noted treatments on 9.2.2025, 11.5.2025 as required by the orders noted on the electronic medical record. The facility failed to ensure that Resident #3's treatment administration record noted treatments on 10.3.2025, 10.10.2025, 10.15.2025, 10.26.2025, 11.2.2025 as required by the orders noted on the electronic medical record. This failure could place residents at risk of not receiving necessary care and services daily as ordered by the physician to promote proper healing 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.

Based on observation, interview, and record review the facility failed make sure that drugs were stored properly and only authorized persons had access to one of two carts reviewed for drug storage and labeling on Hall A 3rd floor.The facility failed to ensure the 3rd floor Hall A medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings Included:Observation of 3rd floor Hall A medication cart on 11/25/2025 at 3:29 PM revealed it was unattended and locked with each drawer opening when pulled. LVN A was seated at the nurse's station and was ask to review the cart. The medication cart was up against the wall in the 3rd floor Hall A corridor. The locking mechanism was pushed in signifying a locked position and was not secured with each drawer opening when pulled. The cart contained prescribed medication for residents and over the counter medications. LVN A walked to 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 reviews, the facility failed to ensure resident medical records were 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 11 residents (Resident #1, Resident #2, and Resident #4) reviewed for clinical records. 1. The facility failed to obtain a physician's order to provide Resident #1 with indwelling catheter care and monitoring for 12 of 12 days (06/28/2025 to 07/09/2025) after admission and failed to ensure Resident #1's daily indwelling catheter care was documented in her medical record for 2 of 12 days (07/08/2025 and 07/09/2025). 2. The facility failed to obtain a physician's order to provide Resident #2 with indwelling catheter and monitoring for 2 of 3 days (06/22/2025 and 06/23/2025) after admission. 3. The facility failed to ensure Resident #4's weekly skin assessments were documented in his medical record for 2 of 15 weeks (the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 of 4 (Residents #1 and #2) reviewed for assessments. 1. The MDS Coordinator failed to complete Resident #1's admission comprehensive assessment within 14 days after admission. MDS Coordinator A verified as complete on 07/12/2025. Resident #1 was admitted on [DATE]. 2. The MDS Coordinator failed to complete Resident #2's admission comprehensive assessment within 14 days after admission. MDS Coordinator A verified as complete on 07/13/2025. Resident #2 was admitted on [DATE]. This failure could affect newly admitted residents and result in residents not receiving the care and services as needed.The findings included: 1. Record review of Resident #1's admission Record, dated 07/16/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/10/2025. Resident #1 was noted to be [AGE] years…

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 baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the residents that meets professional standards of quality of care within 48 hours of a resident's admission for 1 of 5 (Resident #1) reviewed for baseline care plans. The facility failed to include Resident #1's catheter care and monitoring in her initial baseline care plan dated 06/28/2025, when Resident #1 was admitted on [DATE]. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life, infection, and hospitalization.The findings included: Record review of Resident #1's admission Record, dated 07/16/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/10/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's Diagnosis Report, undated and accessed 07/14/2025, reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who had an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 of 2 (Resident #3) reviewed for indwelling catheter care. 1. The facility failed to ensure CNA S cleaned Resident #3's indwelling catheter properly during incontinent care. 2. The facility failed to ensure Resident #3's indwelling catheter was secured appropriately and per physician's order. These failure could place residents with indwelling catheters at risk for pain, infection, injury, and hospitalization. The findings included: 1. Record review of Resident #3's admission Record, dated 07/16/2025, reflected Resident #3 was admitted on [DATE]. Resident #3 was noted to be [AGE] years old. Record review of Resident #3's Diagnosis Report, undated and accessed 07/16/2025, reflected Resident #3 was diagnosed with displacement of indwelling urethral catheter (also known as a foley catheter, a tube inserted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure resident medical records were 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 1 of 11 residents (Resident #4) reviewed for clinical records. The facility failed to ensure Resident #4's weekly skin assessments were documented in his medical record for 2 of 15 weeks (the weeks of: 05/15/2025 and 05/22/2025). These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided.The findings included: Record review of Resident #4's admission Record, dated 07/14/2025, reflected a [AGE] year-old male. He was originally admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #4's Diagnosis Report, undated and accessed on 07/15/2025, reflected Resident #4 was diagnosed with type 2 diabetes mellitus, muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #3 and Resident #5) and 2 of 2 staff (CNA S and CNA T) reviewed for infection control. 1. The facility failed to ensure CNA S properly secured her personal protective equipment during indwelling catheter and incontinent care for Resident #3 on 07/16/2025. 2. The facility failed to ensure CNA T wore appropriate PPE for EBP during indwelling catheter and incontinent care for Resident #5 on 07/16/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included: 1. Record review of Resident #3's admission Record, dated 07/16/2025, reflected Resident #3 was admitted on [DATE]. Resident #3 was noted to be…

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 had a right to a safe, clean, comfortable, and homelike environment for 3 (Residents #147, #148 and #207) of 32 residents reviewed, in that: 1. The bathroom shower faucet handle used by Resident #147 and Resident #148 was broken. 2. The toileting chair used by Resident #207 had a rusty metal support frame with peeling paint in front of and under the seat. This failure could result in psychosocial harm due to diminished quality of life. The findings included: 1. Record review of Resident #147's face sheet, dated 5/16/25, revealed the [AGE] year resident was admitted to the facility on [DATE] with diagnoses including: obstructive hydrocephalus (a condition in which cerebrospinal fluid is blocked in the brain), hypotension (a condition of low blood pressure), and anxiety disorder (a condition in which there is excessive worry about every- day situations). 2. Record review of Resident #148's face sheet dated 5/16/25,…

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 identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 3 of 3 residents (Resident #34 , Resident #55, and Resident #74) whose records were reviewed for PASRR services. The facility failed to recognize during the Level I PASRR screening that Resident #34 and Resident #55 were diagnosed with major depressive disorder, while Resident #74 was diagnosed with schizoaffective disorder and bipolar disorder. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnosis. The findings included: 1. Record review of Resident #34's admission sheet, dated 5/14/25, noted a [AGE] year-old resident admitted to the facility on [DATE] with a diagnoses of major depressive disorder. Record review of Resident #34's quarterly MDS assessment, dated 2/5/25, noted that the resident's BIMS was 15, indicating intact cognition. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 28 residents (Residents #24, #247, #91, and #84) reviewed for comprehensive care plans in that: 1. Resident #24's diagnoses of allergies and constipation were not included in her care plan. 2. Resident #247's care plan was not updated to reflect the removal of his foley catheter. 3. Resident #91's care plan, initiated 03/11/2025 was not updated to reflect an order dated 05/09/2025 for a WanderGuard (a wander management system designed to help prevent residents from wandering off and potentially getting lost or injured). 4. Resident #84 was admitted on [DATE] and re-admitted on [DATE] with a nephrostomy tube (a thin, flexible tube inserted into the kidney…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility in that: 1. The facility failed to maintain a garbage bin under the hand sink to collect dirty hand towels after use. 2. The facility failed to date a package of cheese and two 5 lb containers of cottage cheese in the refrigerator. 3. The facility failed to date a container of 7 ounces of dried rice in the dry storage room. 4. The facility failed to replace to overhead light bulbs in the dish machine room 5. The facility failed to cover two sections of floor baseboard in the main kitchen area that had an uncovered paint surface. 6. The facility failed to secure a ceiling tile in the main kitchen that showed exposed insulation underneath the tile. These failures could place residents at risk for food borne illness. The findings included: Observation on 05/013/2025 from 9:15am until 9:50am with the Food Service Director at revealed the following: a. There was not a garbage can…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 3 (Resident #10, Resident #24, and Resident #28) of 33 residents reviewed for medical records, in that: 1. Resident #10's clinical record included Nurse Practitioner notes which referred to another resident. 2. Resident #24's diagnosis of Osteoporosis was not included in her diagnoses list. 3. Resident #28's diagnosis of Depression was not included in her diagnoses list. These failures could result in inadequate care due to incomplete and inaccurate medical records. The findings were: 1. Record review of Resident #10's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Anemia and Hypertension. Record review of Resident #10's progress notes as of 05/15/2025 revealed the Nurse Practitioner entered visit notes dated 03/11/2025, 01/26/2025, and 12/29/2024 which referred to another resident. 2. 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.

Based on observation, interview, and record review, the facility failed to provide a resident environment that was free of pests for 1 of 1 facility reviewed for effective pest control in that: The facility failed to provide a resident environment that was free of pests as live roaches were observed in Resident #9's bathroom and in the facility conference room This deficient practice could result in illness and/or psychosocial harm for residents living in areas with insects. The findings included: Observation on 05/13/2025 at 11:15 a.m. in Resident #9's bathroom, revealed a live roach crawling on the bathroom wall near a vent in the wall. Observation on 05/13/2025 at 3:40 p.m. revealed a live roach crawling on the surveyor's bag in the facility's first-floor conference room. During an interview with Resident #9 on 05/13/2025 at 11:15 a.m., Resident #9 stated that he had seen roaches coming out of the vents in his shower room and had one crawl on him in bed 2 nights prior. He stated that he has seen the pest control company come out to spray in his room, but did not feel it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record 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 residents (Resident #29) reviewed for call lights. The facility failed to ensure Resident #29'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 #29's face sheet dated 5/14/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #29 had diagnoses that included Major Depressive Disorder (a severe mood disorder that can affect a person's thoughts, feelings, and ability to perform daily activities), Dementia (a decline in cognitive function, including thinking, remembering, and reasoning, severe enough to interfere with daily life) 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 interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 (Resident #28) of 33 residents reviewed for advanced directives, in that: Resident #28's OOH-DNR was missing a physician's signature and was therefore invalid. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will. The findings were: Record review of Resident #28's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. Record review of Resident #28's Quarterly MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #28's care plan, revised [DATE], revealed, [Resident #28] has elected DNR status. 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 observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #72) reviewed for privacy, in that: The facility failed to ensure that MA D locked the computer after she walked away and left the computer unattended , which exposed Resident #72's morning medication list . This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #72's face sheet dated 5/14/25 reflected an [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Heart Failure (condition in which the heart isn't pumping as well as it should) and Atrial Fibrillation (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess each resident using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 3 (Resident #54, #40, and #81), of 33 residents reviewed for timely assessment, in that: 1. Resident #54's Quarterly MDS, dated [DATE] and Annual MDS, dated [DATE] had been initiated but not completed. 2. Resident #40's Quarterly MDS, dated [DATE] and Quarterly MDS, dated [DATE] had been initiated but not completed. 3. Resident #81's Quarterly MDS, dated [DATE] had been initiated but not completed. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information. The findings were: 1. Record review of Resident #54's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Muscle Weakness. Record review of Resident #54's clinical record, as of 05/14/2025, 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 encode and transmit resident assessments in a timely manner for 3 (Residents #200, #57, and #33) of 33 reviewed for resident assessments, in that: 1. Resident #57's Quarterly MDS, dated [DATE], was completed but not transmitted to CMS as of 05/14/2025. 2. Resident #33's Quarterly MDS, dated [DATE], was completed but not transmitted to CMS as of 05/14/2025. 3. Resident #200's Entry MDS, dated [DATE] was completed, but not transmitted to CMS within 14 days of completion. These deficient practices placed residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: 1. Record review of Resident #57's face sheet, dated 05/16/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Lupus Anticoagulant Syndrome. Record review of Resident #57's clinical record, as of 05/14/2025, revealed a list of MDS assessments beginning with the resident's admission.…

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 1 of 20 residents (Resident #72) reviewed for assessments: Resident #72's quarterly MDS, dated [DATE], did not include a diagnosis of depression. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #72's face sheet dated 5/14/25 reflected an [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Heart Failure (condition in which the heart isn't pumping as well as it should) and Depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest ) Record review of Resident #72's monthly physician orders, dated 05/15/2025, revealed the resident had medication order for Buspirone 5 mg tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #211 and #200) of 8 residents reviewed for baseline care plans. 1. The facility failed to include Resident #211's use of anti-coagulants (medications that prevent or slow down the formation of blood clots) in his baseline care plan. 2. The facility failed to include Resident # 200's preference to receive a Kosher diet in her baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: Record review of Resident #211's admission Record dated 05/14/2025 revealed a [AGE] year-old resident with an admission date of 05/05/2025, with primary diagnoses which included: Heart Failure (condition where heart does not pump as well as it should) and Atrial Fibrillation (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #72) reviewed for unnecessary medicines, in that: The facility failed when in May 2025 Resident #72 received buspirone 5 mg twice a day for depression and Resident #72 received escitalopram 10 mg once a day for depression , reflecting a duplication of therapy when Psychotropic medications will not be given in excessive dosage. This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications. The findings included : Record review of Resident #72's face sheet dated 5/14/25 reflected an [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Heart Failure (condition in which the 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 observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 2 medication rooms (Hall 200 medication room) and 1 of 6 medication carts (300 Hall Nurse cart) reviewed for safe medication storage. The facility failed when: 1. There were 2 expired medications for Resident #72 stored on the shelf in the Hall 200 medication room on 05/15/2025. 2. There was a sealed, unopened box of Semaglutide 4mg/3ml (a prescription medication used to Diabetes Type 2 and manage weight) for Resident #212, stored at room temperature inside the Hall 300 Nurse medication cart on 05/15/2025. There was a blue label marked Refrigerate on the outside of the box. 3. There was an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual religious and cultural nutritional needs for 1 of 8 residents (Resident #200) reviewed for religious and cultural dietary needs. The facility failed to provide Resident #200 with a no pork Kosher diet (a diet which follows Jewish dietary laws, which has as a core principate that meat and dairy cannot be consumed together and only certain animals and birds are considered kosher) for the first 5 days after her admission on [DATE]. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their religious nutritional preferences met. The findings included: Record review of Resident #200's admission Record, dated 05/14/2025 revealed the resident was admitted on [DATE] with diagnoses which included: Fracture of unspecified part of neck of right femur (thigh) and irritable bowel syndrome…

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

Based on observation, interviews, and record reviews, the facility failed to 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 7 residents (Resident #9) reviewed for infection control, in that: The facility failed to ensure CNA-H consistently sanitized her hands in between glove changes while providing wound care for Resident #9 on 05/15/2025, This deficient practice could place residents at-risk for infection due to improper care practices. These findings included: Record review of Resident #9's face sheet, dated 5/14/2025, revealed an admission date of 03/15/2024 with re-admit on 02/17/2025, with diagnoses which included: Sequelae of cerebral infarction; Type 2 Diabetes Mellitus; and Edema Record review of Resident #9's MDS Quarterly assessment, dated 04/02/2025 revealed the resident had a BIMS score of 15, indicating normal cognition. Resident #9 was assessed as having one stage 3 pressure ulcer (full-thickness…

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 all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 8 wheelchairs reviewed for essential equipment. The facility failed to ensure Resident #198's wheelchair brakes were functioning correctly on 05/13/2025. These failures could place residents at risk of not having functional and safe mode of mobility. Findings include: Record review of Resident #198's admission Record dated 05/16/2025 revealed a [AGE] year-old resident admitted on [DATE] with diagnoses which included: Fracture of part of neck of unspecified femur (break in part of thigh bone that connects to hip joint); repeated falls; and unsteadiness on feet. Record review of Resident #198's admission MDS assessment dated [DATE] revealed a BIMS score of 14, indicating normal cognition. She was assessed as using a wheelchair for mobility and needing partial/moderate assistance for bed to chair transfers. Record review of Resident #198's 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 observations, interviews, and record reviews the facility failed to ensure each resident received food prepared in a form designed to meet individual needs, for 1 of 8 residents (Resident #1) reviewed for nutritional needs. The facility failed to provide a fortified meal plan from 1/4/2025 to 4/24/2025 for Resident #1 as ordered by the physician and the dietician. This failure could place residents at risk for harm by weight loss. The findings included: A record review of Resident #1's admission record, dated 4/23/2025, revealed an admission date of 11/9/2024 with diagnoses which included vascular dementia (a group of symptoms affecting memory, thinking and social abilities caused by strokes), cerebral infarction (strokes), and chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood well). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score…

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 maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for one (Resident #1) out of three residents reviewed for documentation of wound care dressing changes. The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #1 on 03/14/2025, 03/15/2025, 03/16/2025, 03/19/2025, 03/22/2025, and 03/23/2025. These failures placed residents at risk for missed treatments and care which could result in the wound deterioration, and development of infection. Findings included: Record review of Resident #1's face sheet, dated 03/26/2025, revealed the resident was [AGE] years old, male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnosis of cellulitis of left lower limb (skin infection), abnormity of gait and mobility, cerebral infarction (disrupted blood flow to the brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 2 of 3 residents (Resident #1 and #2) reviewed for pressure injuries. 1. The facility nurses did not provide wound care to Resident #1 on 03/20/2025 and 03/24/2025. However, the physician order indicated Cleanse left glute, lateral malleolus, medial calf, and right plantar with wound cleanser, gently pat dry with gauze, apply skin prep to peri wound, apply medi-honey, cover with calcium alginate and secure with dry dressing daily - every day. 2. The facility nurses did not provide wound care to Resident #2 on 03/25/2025. However, the physician order indicated Cleanse third digit right toe with wound cleanser, gently pat dry with gauze, apply betadine and LOTA (leave open to air) daily - every day. This failure could place residents at risk of improper…

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 objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 7 residents (Resident #3) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #3's ADL needs; indwelling catheter use; diagnoses and treatments including blood pressure, antidepressants, and antiplatelet medications; dietary needs, including requiring a mechanically altered diet; therapy; and discharge planning. This deficient practice could affect residents and place them at risk for not having their needs and preferences met. Findings included: Record review of Resident #3's admission Record, dated 10/25/24, revealed the resident was admitted to the facility on [DATE] 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 interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 1 of 3 residents (Resident #3) reviewed for medication administration. The facility failed to administer Carvedilol (a medication used to treat HTN) to Resident #3 per physician's orders. This deficient practice could place residents at risk of not receiving the therapeutic benefit of prescribed medication or a decline in health. Findings included: Record review of Resident #3's admission Record, dated 10/25/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood), atherosclerotic heart disease (damage in the heart's major blood vessels), Hypertension (high blood pressure), and Angina Pectoris (chest pain caused by reduced blood flow to the heart). Record review of Resident #3's comprehensive MDS, dated [DATE], revealed the resident had a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure resident medical records were 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 1 of 7 residents (Resident #3) reviewed for clinical records. The facility failed to ensure Resident #3's EMR reflected accurate HR on 10/20/24. These failures could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #3's admission Record, dated 10/25/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Acute Kidney Failure (condition in which kidneys suddenly are unable to filter waste from blood), atherosclerotic heart disease (damage in the heart's major blood vessels) , Hypertension (high blood pressure), and Angina Pectoris (chest pain caused by reduced blood flow to the heart). Record review of Resident #3's comprehensive MDS,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to transcribe Resident #1's discharge orders and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented timely, which caused him to miss getting his medications for four (4) to five (5) days. This failure could cause a delay in appropriate medical care and worsening in symptoms, condition, or illness. The findings included: Record review of Resident #1's admission Record, dated 07/30/2024, indicated he was a [AGE] year-old male admitted on [DATE]. Record review of Resident #1's Medical Diagnosis list in the facility's EMR included: COVID-19 (An illness that can affect a person's lungs and airways caused by a virus called the Coronavirus),…

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 had a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment ans supports for daily living safely for 4 of 30 rooms (Rooms #309, #316, #328, and #330) on the third floor of the facility and 1 of 3 halls (Hall C) on the third floor of the facility, in that: 1. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER]. 2. The facility failed to repair a wall scrape behind a resident bed in room [ROOM NUMBER]. 3. There were 2 of 3 light bulbs burnt in room [ROOM NUMBER]. 4. The wall between Rooms #328 and #330 showed signs of water damaged. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: During an observation tour on 04/05/2024 from 10:45-10:50 a.m. with the Maintenance Director and the Administrator the following was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that each resident received food that was served at a safe and appetizing temperature for 2 (Residents #1 and #77) of 22 Residents reviewed for palatable food in that: Residents #1 and #77 reported receiving cold food at mealtimes. This failure could place residents at risk of not being satisfied with their food or encouraged to increase their personal food intake with an outcome of weight loss and a diminished quality of life. The findings were: 1. Record review of Resident #1's face sheet, dated 4/5/24, revealed the resident was last admitted to the facility on [DATE] with diagnoses including cerebral palsy ( a congenital disorder of movement, muscle tone, or posture), generalized anxiety disorder ( a condition of severe ongoing anxiety that interferes with daily activities), and hypertension( a condition of elevated blood pressure). Record review of Resident # 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. [NAME] A was preparing food in the kitchen and did not have a facial hair restraint covering his facial hair. 2. The DM wore jewelry on his wrist while engaged in food preparation in the kitchen. 3. In the walk-in cooler there was a quart of heavy cream that was opened and not labeled with a use-by date and a container of Thickened Dairy Beverage past the use-by date. 4. In the dry storage room there were two small plastic bowls filled with crispy rice cereal that were not sealed, labeled and dated, and a #10 can of tomatoes on the floor. 5. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 04/02/2024 at 12:02 PM in the kitchen revealed [NAME] A completed food preparation for 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 interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, 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 5 residents (Resident 4) reviewed for care plans. The facility failed to care plan Resident #4's self-care for colostomy. This failure could place residents at risk of not having their needs met. Finding Included: Record review of Resident #4's face sheet, dated 4/4/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses that included Acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Chronic obstructive pulmonary disease, (refers to a group of diseases that cause airflow blockage and breathing-related problems), and Anxiety disorder (involves a constant feeling of anxiety or fear). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #4) reviewed for medication storage, in that: The facility failed to ensure medications were not left on Resident #4's bed side table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered. The findings were: Record review of Resident #4's face sheet, dated 4/4/24, revealed an [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), Chronic obstructive pulmonary disease, (refers to a group of diseases that cause airflow blockage and breathing-related problems), and Anxiety disorder (involves a constant feeling of anxiety or fear). Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated 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.

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 7 residents (Resident #58) reviewed for infection control, in that: While administering medications for Resident #58, RN E touched the light fixture pull cord and power plug and, the bed remote with her gloved hands and did not changed her gloves and washed her hands before touching Resident #58's eyes area and administering eye drops to the resident. These failures could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #58's face sheet, dated 04/05/2024, revealed an admission date of 12/24/2021, and a readmission date of 06/28/2023, with diagnoses which included: Dysphagia (Difficulty in swallowing), Insomnia (Difficulty sleeping), Hemiplegia (Paralysis of one side of the body), Cerebral infarction (process that result in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide the necessary care and services to a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming for 1 of 6 residents (Resident #2), reviewed for activities of daily living, bathing and grooming, in that: Resident #2 was not provided with grooming of her facial chin hair which appeared to measure over a quarter of an inch. This deficient practice could result in residents experiencing a diminished quality of life. The findings were: Record review of Resident #2's face sheet, dated 2/15/24, and EMR revealed, the resident was re-admitted on [DATE] with diagnoses that included: encephalopathy (brain disease that alters brain function or structure), need for assistance with personal care, and chronic kidney disease. Further review revealed the resident was a female; age [AGE], and the resident's RP was listed as: Family Member. Record review of Resident#2's MDS , dated 1/18/24,…

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 for a resident who is incontinent of bladder appropriate treatment, and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #5) reviewed for catheter care, in that: Resident #5's urinary catheter bag with urine was not anchored to the bed frame and lying on the floor. This deficiency could prevent residents on catheter treatment from receiving appropriate services and could lead to blockage in urine flow and infection. The findings were: Record review of Resident #5's face sheet, dated 2/15/24, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: hospice, Huntington's disease (a neurological disorder), aphasia (cannot communicate), and stage 4 pressure ulcer (right buttocks). Record review of Resident#1's MDS, dated [DATE], revealed the resident had a BIMS score of 0, which indicated the resident was severely 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, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 3 of 6 residents (Residents #1 #2, and #4) reviewed for accommodations of needs. The facility failed to ensure Residents (#1, #2, and #4,) call lights were answered in a timely manner when they needed assistance. This failure could place residents at risk of not receiving care or attention needed. The findings were: Record review of Resident #1's face sheet dated 1/6/2024 revealed an [AGE] year-old male with an admission date of 12/29/2023. His diagnosis included chronic kidney disease stage 3(your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood.), vascular dementia(is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage), polyneuropathy(is when multiple peripheral…

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 failed to ensure that it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident for 4 of 6(Residents #1, #2,#3,#4,) residents. 1. The Administrator failed to ensure nursing staff were performing showers on Residents (1,2,3,4) causing the residents to receive no showers or only 3 showers in a two week period. 2. The Administrator failed to ensure all staff were answering resident call lights in a timely manner when they needed assistance. This could place residents at risk of not receiving care or attention needed. The findings were: Record review of Resident #1's face sheet dated 1/6/2024 of an [AGE] year-old male with an admission date of 12/29/2023 revealed diagnoses of chronic kidney disease stage 3(your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your 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 provide the necessary services to maintain good personal hygiene for 4 of 5 residents (Residents #1, #2, #3, and #4,) reviewed for activities of daily living. 1. Resident #1 had no showers between dates of 12/29/2023-1/7/2024. 2. Resident #2 had 3 showers between dates of 12/25/2023-1/7/2024. 3. Resident #3 had 2 showers between dates of 12/25/2023-1/7/2024. 4. Resident #4 had 2 showers between dates of 12/25/2023-1/7/2024. This failure could affect residents and contributed to feelings of hopelessness and frustration. The findings were: Review of Resident # 1's face sheet dated 1/6/2024 revealed admission into facility on 12/29/2023 with diagnoses to include chronic kidney disease, stage 3(mild to moderate loss of kidney function.),vascular dementia without behavioral disturbance(A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 15 residents (Resident #5) and for 1 of 1 facility in that: The facility failed to adequately clean a resident dining room following meal service, clean a table over a two-day period, clean a spilled liquid area in cabinet holding the juice machine pump, repair broken shelving in a kitchen cabinet, repair a broken piece of kitchen cabinet surface, repair a broken kitchen cabinet door hinge, replace three missing ceiling tiles, and repair a resident's broken window blind. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Record review of Resident #5's face sheet, dated 11/8/23, revealed a [AGE] year old resident who was originally admitted to the facility on [DATE] with diagnoses which included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately notify the resident representative for 1 of 1 resident (Resident #1) reviewed for changes in condition. The facility failed to notify the Resident's # 1 's family member of a positive pneumonia diagnosis. This deficient practice could result in denial of resident rights of family to be notified with any change of status criteria. Failure to notify family members of significant change of status could affect any resident at risk for hospitalization. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, [Chronic obstructive pulmonary disease] a chronic inflammatory lung disease that causes obstructed airflow from the lungs, and [Type 2 diabetes] a condition that happens because of 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure all staff were wearing hairnets while in the kitchen. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 11/08/2023 at 8:26 a.m. revealed DA B washing dishes. At 8:28 a.m., DA B stepped into the kitchen area where breakfast trays were being plated by the DS and another dietary aide. DA B was not wearing a hairnet. During an observation and interview with DA B on 11/08/2023 at 8:30 a.m., DA B revealed herself to be a dishwasher. She further explained she had been running late and hurried in to help with the dishes. DA B stepped out of the kitchen and took a hairnet from a box by the kitchen entrance that was labeled for no one to enter kitchen without a hairnet. During an interview with the Dietary Supervisor on 11/08/2023 at 11:11 a.m., 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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 3 of 8 residents (Resident #233, Resident #237, and Resident #230) reviewed for a baseline care plan, in that: 1. The facility failed to ensure Resident #237's baseline care plan, undated, revealed no focus area or interventions for resident #237's use of pain medication [Norco]. 2. The facility failed to ensure that Resident #233's baseline care plan included information related to the resident's diagnosis of diabetes mellitus. 3. The facility failed to ensure that Resident #230's baseline care plan included information related to the resident's diagnosis of diabetes mellitus and bipolar disorder. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing…

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 that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 4 of 24 residents (Residents #58, #35, #74, and #233) reviewed for care plans, in that: 1. The facility failed to develop a comprehensive care plan that addressed Residents #58's anti-coagulant therapy. 2. The facility failed to develop a comprehensive care plan that addressed Resident #74's anti-coagulant therapy. 3. The facility failed to develop a comprehensive care plan that addressed Resident #233's anti-coagulant therapy. 4. The facility failed to develop a comprehensive care plan that addressed Resident #35's cognitive communication deficit. These deficient practices could place residents at risk of receiving inadequate interventions that are not individualized to their care needs. The findings included: 1. Record review of Resident #58's…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: The facility failed to ensure plastic storage containers used to store dry cereal in the dry storage room of the kitchen were properly sealed. This deficient practice could place residents who received meals and snacks from the kitchen at risk for food borne illness. The findings included: Observation on 02/21/2023 at 10:05 a.m. revealed there were three 6-quart plastic containers used to store dry cereal. One container contained crispy rice dry cereal and was filled to the 2-qt. mark. One container contained corn flakes dry cereal and was filled approximately halfway. One container contained toasted oats dry cereal and was completely full. All three containers had plastic lids that were slightly ajar, revealing an open space at the top of the container. Interview with the Dietary Manager (DM) on 02/21/2023 at 10:07 a.m. confirmed that all three containers of dry cereal…

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 the interview and record review, the facility failed to ensure the MDS assessments accurately reflected the resident's status for 1 of 8 residents (Resident #230) reviewed for accuracy of assessments. 1. The facility failed to ensure the MDS assessment reflected Resident #230's diagnosis of diabetes Mellitus. 2. The facility failed to ensure the MDS assessment reflected Resident #230's diagnosis of bipolar disorder. These deficient practices could place the residents at risk of not receiving the necessary care and services. The findings included: 1. Record review of Resident #230's face sheet, dated 2/23/2023, revealed a 93- year old male admitted to the facility on [DATE] with diagnoses that included: [Type 2 diabetes mellitus] with hyperglycemia (high blood sugar level), [Atrial fibrillation] is irregular. Often very rapid heart rhythm can lead to blood clots in the heart. [Low Blood Pressure] Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm…

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 employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager (DM) reviewed for qualified dietary staff, in that: The DM failed to ensure there were recipes for all pureed menu items in the kitchen. This failure could place residents prescribed a pureed diet at risk for not receiving adequate nutrition and/or weight loss. The findings included: Review on 02/23/2023 at 10:45 am of the recipe binder in the facility's only kitchen revealed did not contain recipes with instructions on how to prepare pureed menu items for residents prescribed a pureed diet. Review of the menu for the pureed diet for Day 3, Week 2 of the menu cycle revealed it was: Pureed fried chicken (1/2 cup); cream gravy, 1/4 cup; pureed mashed potatoes, 1/2 cup; pureed honey-glazed carrots, 3/8 cup; pureed roll, 3/8 cup; margarine, 1 each; pureed lemon bar, 1/4 cup. Review of the Resident Diet Roster provided by the facility on 02/21/2023 revealed there were seven…

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.