The Enclave

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one resident (#41) out of .three residents reviewed for indwelling urinary catheters. The facility failed to have a diagnosis or physicians order for August 2025 for Resident #41's indwelling urinary catheter. This deficient practice affects residents with indwelling urinary catheters and could result in an inconsistency of care. The findings included: Record review of Resident #41's electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one (Resident #174) of six Residents who were reviewed for respiratory care. Resident #174's tubing and mask which were attached to a nebulizer for the resident's breathing treatment were not covered in a plastic bag when not in use. This deficient practice could place residents at risk of respiratory distress, infections, pneumonia and an overall decline in their physical condition.The findings were: Record review of Resident #174's face sheet, dated 08/27/2025, revealed the resident was 70-years-old male who was admitted to the facility on [DATE] with diagnosis of lack of coordination (uncoordinated movement is due to a muscle control problem), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41% based on 2 errors out of 27 opportunities, which involved one (Residents #150) of seven residents reviewed for medication errors. a. LVNO did not administer Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to both his eyes for dry eyes because the medication was not available on 08/25/2025 at 4:39 p.m. b. LVNO administered Resident #150's Timolol maleate 0.5 % eye drop for glaucoma on 08/25/2025 at 4:39 p.m., but the order and schedule was Administer Timolol maleate 0.5 % eye drop for glaucoma every 12 hours to Resident #150 at 8:00 am and 8:00 pm. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders.Findings include: Record review of Resident #150's face sheet, dated…

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 biological were stored in locked compartments for 1 (treatment cart) of 5 nursing carts and 1 resident (Resident #34) of 32 residents reviewed for storage, in that: 1. The facility failed to ensure the treatment cart was locked when left unattended. 2. The facility failed to notice and remove a jar of medicated chest rub from Resident #34's nightstand. This failure could place residents at risk of misappropriation of medications and not receiving therapeutic benefits of medications. The findings were: 1. During an observation on 08/25/2025 at 10:50 a.m., revealed the treatment cart was found unlocked and unattended on the 300-unit B-hallway. This surveyor was able to open all drawers revealing multiple medications and ointments, scissors, and bottles of medications. During an interview on 08/25/2025 at 10:52 a.m., the wound care nurse stated the treatment cart was unlocked and unattended on the 300-unit B-hallway. 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #2) reviewed for pharmacy services.LVN A did not administer Resident #2's Famotidine (Pepcid) 10 mg oral one tablet a day for indigestion on 07/20/2025 because she could not find the medication in the medication cart where it was stored. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings were:Record review of Resident #2's admission Record (Face Sheet), dated 07/21/2025, revealed she was [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (decline in mental ability which can interfere with daily life) and GERD without esophagitis (a chronic condition when stomach…

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 medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 4 of 5 residents (Resident #1, #2, #4, and #5) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in April and May 2025. 2. The facility failed to ensure Resident #2's bath or shower was documented as given or as refused 6 times in April and May 2025. 3. The facility failed to ensure Resident #4's bath or shower was documented as given or as refused 11 times in April and May 2025. 4. The facility failed to ensure Resident #5's bath or shower was documented as given or as refused 8 times in April and May 2025. These failures could place residents at risk for improper care due to inaccurate records. Findings included: 1. Record review of Resident #1's admission Record (face sheet) dated 05/04/2025 revealed she was admitted 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.

Based on observations, interviews, and record reviews, 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: 1. The CDM wore a hair restraint that did not cover all his hair. 2. In the freezer, there was frozen raw beef stored over fully cooked frozen pies. 3. In the walk-in cooler, there were: a. Uncovered foods of 3 trays of pie desserts, 2 trays of bowels of fruits, and 1 tray of plates of salad. b. Cheese that was inappropriately stored. c. The CDM revealed he did not label prepare foods with a discard date. 4. In the dish room, the temperature log of the dishwashing machine had the wrong temperature 5. For 06/28/24 lunch, fortified shakes and yogurt temperatures were taken by touching the thermometer outside of the food product and not inside of the food product. 6. The refrigerators' temperature in the kitchen were only checked one time a day. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. 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 ensure each resident was free of any significant medication errors for 1 of 8 residents (Resident #35) reviewed for medications. The facility failed to provide Resident #35 with Diltiazem HCl Oral Tablet 30 MG (treats high blood pressure) as Diltiazem HCl Oral Tablet 30 MG Give 1 tablet by mouth three times a day for heart Monitor BP hold medication if SBP <110 or HR <60 bpm notify MD This deficient practice could result in a risk to the residents' health and complications which can lead to symptoms of heart failure. The findings included: Record Review of Resident #35's admission record, dated 06/27/24, reflected a [AGE] year-old female with an admission date of 05/31/18 and a re-admission date of 02/12/24, reflected diagnoses to include Paroxysmal Atrial Fibrillation (a type of irregular heartbeat that can cause blood clots, stroke and heart failure) and Essential (Primary) Hypertension (high blood pressure). Record review of Resident #35's 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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 4 (Resident #29, #228, #2, #100 and #4) of 23 residents reviewed, in that: 1. Resident #29's personal refrigerator was dirty with old and brown colored food debris. 2. Resident #228's personal refrigerator had undated soup with rice. 3. Resident #2's personal refrigerator's door was broken and not closed perfectly, and there was one opened food item unlabeled and undated in the refrigerator. 4. Resident #100's personal refrigerator had undated fried chicken. 5. Resident #4's personal refrigerator had expired foods in it. The findings were: 1. Record review of Resident #29's electronic face sheet, dated 06/28/2024, reflected she was female and admitted to the facility on [DATE]. Her diagnoses included: critical illness myopathy (disease that affects the muscles), type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 23 Residents (Resident #4 and Resident #49) who were observed for call light placement. Nursing staff failed to ensure the call light was within reach for Resident #4 and Resident #38. This deficient practice could affect any resident and keep them from calling for help as needed. The findings were: 1. Review of Resident #4's face sheet, dated 6/28/24, revealed she was admitted to the facility on [DATE] with diagnoses including Aphasia following Cerebral Infarction, other recurrent Depressive Disorders and Persistent Mood (Affective) Disorder. Review of Resident #4's quarterly MDS assessment, dated 2/8/24, revealed Resident #4 was usually understood and usually understood, her BIMS was 11 out of 15 reflecting moderate cognitive impairment and she required assistance with all ADL's by 1 to 2 person's except for eating. 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 assessments accurately reflected the resident's status for 2 of 10 Residents (Resident #38, and Resident #116) whose MDS records were reviewed for accuracy. 1. The facility failed to ensure Resident #38's Quarterly MDS assessment dated [DATE] documented Resident #38 received a therapeutic diet while a resident at the facility. 2.The facility failed to ensure Resident #116's discharge MDS assessment, dated 04/29/2024, accurately reflected the resident's discharge status. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: 1. Record review of Resident #38's face sheet dated 06/27/2024, revealed Resident #38 was admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus without complications, dysphagia, oropharyngeal phase, and unspecified protein-calorie malnutrition. Record review of Resident #38's physician order summary dated 06/27/2024, 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 interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 2 residents (Residents #13) reviewed for PASRR screening, in that: Resident #13's PASRR Level 1 assessment did not accurately capture the resident's diagnosis of mental illness. These failures could put residents with inaccurate PASRR Level 1 Evaluations at risk of not receiving care and services to meet their needs. The findings were: Record review of Resident # 13's face sheet dated 6/26/24 revealed a [AGE] year-old female admitted to the facility 5/3/24 with diagnoses that included Post Traumatic Stress Disorder ( a disorder that develops in some people who have experienced a shocking, scary, or dangerous event), Hypertension (a condition where the pressure in your blood vessels is consistently too high), and Peripheral vascular disease,( is a progressive disorder that affects blood vessels…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident 51) whose records were reviewed for ADL care. Nursing staff failed to wash his face, apply cream to his face, to clean his lips and cut his finger nails for 1 of 4 observations. These deficient practices could affect any dependent resident and could lead to the resident's decline in their physical health. The findings were: Review of Resident #51's face sheet, dated 6/28/24, revealed he was admitted to the facility on [DATE], with diagnoses of Traumatic Brain Injury (TBI) without loss of consciousness, sequela, Narcolepsy in conditions classified elsewhere with cataplexy and Gastrostomy Status. Review of Resident #51's annual MDS assessment, dated 3/14/24, revealed he was unable to complete the BIMS because he was rarely/never understood. His BIMS was severe…

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 fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #103) of 2 residents reviewed for enteral feeds. The facility failed to ensure Resident #103's water with enteral feed was properly administered at the correct rate of infusion. This failure could place residents at risk of not receiving the proper hydration requirements prescribed by the physician. Findings included: Record review of Resident #103's electronic face sheet, dated 06/28/2024, reflected he was male and originally admitted to the facility on [DATE], and re-admitted on [DATE]. His diagnoses included: muscle wasting and atrophy (decrease in size and wasting of muscle tissue), type 2 diabetes mellitus (trouble controlling blood sugar), cirrhosis of liver (chronic liver damage), pressure ulcer of sacral region (bedsore to buttock), dysphagia (difficulty swallowing), 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 that Residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #66) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #66's nebulizer mask was properly stored and dated. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Record review of Resident #66's electronic face sheet, dated 06/28/2024, reflected she was female and originally admitted to the facility on [DATE], and re-admitted on [DATE]. Her diagnoses included: displaced trimalleolar fracture of right lower leg (right ankle fracture), asthma (airway becomes inflamed, narrow, and swells, which makes it difficult to breathe), muscle wasting and atrophy (decrease in size and wasting of muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure If a bed or side rail was used, the facility must ensure resident assessment of the resident for risk of entrapment from bed rails for 2 of 7 Residents (Resident #4 and Resident #33) whose records were reviewed for side rail use. Nursing staff did not assess Resident #4 and Resident #33 periodically per facility policy since initial assessment upon admission to the facility. This deficient practice could affect any resident using a side rail and could contribute to avoidable incidents of entrapment. The findings were; 1. Review of Resident #4's face sheet, dated 6/28/24, revealed she was admitted to the facility on [DATE] with diagnoses including Aphasia following Cerebral Infarction, other recurrent Depressive Disorders and Persistent Mood (Affective) Disorder. Review of Resident #4's quarterly MDS assessment, dated 2/8/24, revealed Resident #4 was usually understood and usually understands, her BIMS was 11 out of 15 reflective 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 ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #52) reviewed for medication storage, in that: The facility failed to ensure medications were not left on Resident #52'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 # 52's electronic face sheet dated 6/25/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Benign Prostatic Hyperplasia (prostatic enlargement that can cause urinary difficulty), Hyperlipidemia (condition in which there are high levels of fat particles in blood) and Diabetes Mellitus (condition that can result in too much sugar in the blood). Record review of Resident #52's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #52'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meals (lunch meal on 06/25/2024) reviewed for menus in that: 1. The facility failed to follow the menu for residents on regular and modified diets for the lunch meal on 06/25/2024. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: Record review of Week 2 menu reflected Tuesday 06/25 lunch comprised of lemon pepper chicken, buttered corn, and roasted broccoli for Tuesday 06/25 lunch, and not carrots. Record review of Resident #79's admission record, dated 06/25/2024, reflected the resident was admitted to the facility on [DATE] with diagnoses to include: muscle wasting and atrophy and mild protein-calorie malnutrition. Record review of Resident #79's MDS optional state assessment, dated 06/01/2024, reflected a BIMS score of 15 out of 15, indicating intact cognition. 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 observations, interviews, and record reviews, the facility failed to accommodate residents' food preferences and allergies for 2 of 8 (Residents #35 and #79) residents reviewed for food preferences and allergies, in that: 1. The facility failed to provide Resident #79 with a protein, when he had a listed dislike for the protein served for 06/25/24 lunch. 2. The facility failed to ensure Resident #35 did not receive fish for 06/28/24 lunch, which was listed as a food allergy in her medical record. These failures could cause an allergic reaction, a decrease in resident choices, a diminished interest in meals, placing them at risk for contributing to poor intake and/or weight loss. 1. Record review of Resident #79's admission record, dated 06/25/2024, reflected the resident was admitted to the facility on [DATE] with diagnoses to include: muscle wasting and atrophy and mild protein-calorie malnutrition. Record review of Resident #79's MDS optional state assessment, dated 06/01/2024, reflected 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 observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 Residents (Residents #103 and Resident #51) of 23 residents reviewed for infection control. 1. LVN P entered Resident #103's room, who was on EBP, on 06/26/2024 at 04:10 p.m., and failed to put on a gown when the nurse performed wound treatment for Resident 103. 2. ADON entered Resident #51's room, who was on EBP and failed to wash or sanitize her hands, put on a gown when checking to ensure the G-Tube was connected when the G-Tube pump shut off. These deficient practices affect residents who require direct care and could place residents at risk for cross contamination and infections. The findings were: 1. Record review of Resident #103's electronic face sheet, dated 06/28/2024, reflected he was male, originally admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents. NA E failed to use an assistive device used for lifting and transfers on 4/30/24 when transferring Resident #1, resulting in Resident #1 experiencing pain to her Right ankle and requiring an x-ray. This failure could place residents at risk of injuries and a decline in quality of life. Findings include: Record review of Resident #1's Face Sheet dated 6/6/2024, revealed a [AGE] year old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of muscle wasting, Diabetes Mellitus 2 , cognitive communicative disorder ,recurrent depression, history of fracture right femur(primary leg bone), hyperlipidemia(high cholesterol), and dementia without behaviors. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 11 indicating…

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 routine and emergency drugs and biologicals to its residents for 1 of 5 residents (Resident #4) reviewed for medications, in that: The facility failed to provide Resident #4 with Amiodarone (an antiarrhythmic used to treat heart rhythm problems) on 04/14/2024 resulting in one dose missed; Alprazolam (a sedative used to treat anxiety and panic disorder) on 04/14/2024 resulting in one dose missed; and Loratadine (an antihistamine used to treat allergy symptoms and hives) on 04/14/2024 resulting in one dose missed; Gemtesa (a medication used to treat an overactive bladder) on 04/13/2024, 04/14/2024, and 04/15/2024 resulting in three doses missed; and Latanoprost (a medication used to treat glaucoma) on 04/13/2024, 04/14/2024, and 04/15/2024 resulting in three doses missed. This deficient practice could result in a risk to the residents' health and complications which can lead to stroke, heart failure, sudden cardiac death. 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 treat residents with dignity and respect for 3 of 3 residents (Residents #1, #2 and #3) observed in that: LVN A addressed Residents #1, #2 and #3 as, honey, and, sweetheart. This failure could affect residents' by failing to protect and promote the residents' rights causing them to feel uncomfortable and disrespected. The findings were: 1. Review of Resident #1's electronic face sheet, dated 05/01/2024, revealed she was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with osteomyelitis of vertebra (painful bone infection of the spine), malignant neoplasm of thymus (malignant cancer cells in the thymus), intraspinal abscess and granuloma (infection of the epidural space). Review of Resident #1's quarterly MDS assessment with an ARD of 03/10/2024 revealed Resident #1 had an indwelling catheter and ostomy. Further review of the MDS revealed Resident #1 scored an 15/15 on her BIMS score which indicated she had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving neglect were reported immediately, but 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 1 resident (Resident #1) reviewed for reportable incidents, in that: 1. Facility staff failed to report to the Administrator Resident #1's elopements on 02/25/2024 and 04/28/2024. 2. The facility failed to ensure a report was made to the State Survey Agency regarding Resident #1 being found outside of the facility on 02/25/2024 at 4:51 PM. 2. The facility failed to ensure a report was made to the State Survey Agency regarding Resident #1 being found outside of 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 ensure each resident was free of any significant medication errors for 1 of 5 residents (Resident #4) reviewed for medications. -The facility failed to provide Resident #4 with Amiodarone (an antiarrhythmic used to treat heart rhythm problems), Alprazolam (a sedative used to treat anxiety and panic disorder), and Loratadine (an antihistamine used to treat allergy symptoms and hives) until -The facility failed to provide Resident #4 with Gemtesa (a medication used to treat an overactive bladder) and Latanoprost (a medication used to treat glaucoma) until This deficient practice could result in a risk to the residents' health and complications which can lead to stroke, heart failure, sudden cardiac death. The findings included: Record review of Resident #4's face sheet, dated 05/01/2024, reflected a [AGE] year-old female most recently admitted on [DATE] with diagnoses including: type 2 diabetes (A long-term condition in which the body has…

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 establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #14) observed for infection control, in that: 1. Prior to beginning wound care for Resident #14, LVN A left the prepared wound care supplies unattended in the resident's room 2. During wound care for Resident #14, LVN A wiped from the top of the resident's wound and through the wound. This failure could affect residents who receive wound care and could result in cross contamination. The findings were: Record review of Resident #14's electronic face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with osteomyelitis of vertebra (painful bone infection of the spine), malignant neoplasm of thymus (malignant cancer cells 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 observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 5 residents (Resident #2 and Resident #5) reviewed for drug administration in that: The facility did not ensure Resident #2 and Resident #5 received their 8:00 a.m. medications on time. This deficient practice could affect residents and place them at risk for not receiving a therapeutic effect. The findings were: Record review of Resident #2's face sheet, dated 1/26/24, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease [a group of lung diseases causing constriction of the airways and difficulty breathing], unspecified, unilateral primary osteoarthritis [a type of arthritis that occurs when flexible tissue at the ends of bones wears down], left knee, muscle weakness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #5 and Resident #4) reviewed for infection control in that: 1. LVN A did not sanitize the blood pressure cuff prior to using the wrist blood pressure cuff on Resident #5. 2. Nurse Aide in Training B did not perform hand hygiene after cleansing Resident #4's perineal area and prior to touching Resident #4. This deficient practice could affect residents and place them at risk for infection. The findings were: 1. Record review of Resident #5's face sheet, dated 1/26/24, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of hemiplegia [paralysis of one side of the body] and hemiparesis [muscle weakness of one side of the body] following cerebral infarction [stroke] affecting right…

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 set forth 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 3 of 4 resident reviewed . (Resident #14, Resident #88, and Resident #226) The facility failed to develop a care plan for hypnotic medication use, for the medical management of dementia with behavioral disturbance, insomnia, and hypertension for Resident #14. The facility failed to develop a care plan for anti-depressant medication use, for the medical management of hypertension, and type 2 diabetes mellitus for Resident #88. The facility failed to develop a care plan for anti-anxiety medication use, anti-psychotic medication use, anti-manic medication use, hypnotic medication use or for the medical management of insomnia, hypertension, and dementia…

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 drugs, An unnecessary drug is any drug used without adequate monitoring, for 4 (Resident #88, Resident #226, Resident # 14 and Resident #13) of 4 Residents reviewed for psychotropic medications. The facility failed to have an adequate indication of use, and monitoring for efficacy and adverse consequences for Resident #88 for the use of trazodone HCl 25mg, Venlafaxine HCl ER 15mg, and Xanax 0.5mg. Resident #226, and Resident #14 for the use of psychotropic medications. The facility failed to have an indication of use, and monitoring for efficacy and adverse consequences for Resident #226 for the use of Aripiprazole 10mg, Brexpiprazole 2mg, Lorazepam 1mg, Seroquel 100mg, and trazodone HCl 100mg. The facility failed to have an indication of use, and monitoring for efficacy and adverse consequences for Resident #14 for the use of Quetiapine fumarate (200mg, 50mg, and 25mg), Sertraline HCl 75mg…

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

Based on observations, interviews and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facilities only kitchen. The facility failed to ensure food items past their expiration date were discarded. This failure could place residents at risk for food-borne illness. Findings include: In an observation and interview with DM on 04/17/23 at 9:14 AM a stainless steel, rectangular container covered with clear plastic wrap, was discovered on a shelf in the kitchen walk-in refrigerated space that contained sliced pears, was dated 04/11/23. DM immediately took the container, discarded the contents, and stated that leftover foods should be discarded after 72 hours from the time the food was placed into the refrigerator and that if residents consumed leftovers that were past their discard date the residents could become ill. In an observation and interview with DM on 04/17/23 at 9:17 AM a stainless steel, rectangular container covered in clear plastic wrap, was discovered on a shelf in the kitchen walk-in…

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

Based on record review and interview, this facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis for one (Social Worker) of one Qualified Social Worker reviewed for Social Services. The facility was licensed for 142 and failed to ensure they employed a full-time, qualified social worker since 03/02/23. This deficient practice could result in the residents' social service needs not being met, which could result in a decline in their mental and psychosocial well-being. Findings included: Record review of facility's license revealed the facility had a licensed capacity of 142 residents. Record review of the Administrator's spreadsheet dated 04/21/23 revealed, Social Worker B worked from 08/29/22 to 02/14/23. Record review of the Administrator's spreadsheet dated 04/21/23 revealed, Social Worker C worked from 02/17/23 to 03/02/23 . Record review of the Resident Council Minutes dated 02/28/23 revealed, Concerns: Residents upset that SW left . Record review of the Resident Council Minutes dated 03/08/23 revealed, Concerns: When are we getting a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure the residents received proper treatment to maintain hearing abilities in making appointments for three (Residents #17, #50 and #50) of nine residents reviewed for hearing checkups. The facility failed to follow their own policy with scheduling appointments and did not ensure hearing checkups were completed for Residents #17, #50 and #60. This failure could affect all the residents by placing them at risk of not having their healthcare needs met which could lead to a decline in their hearing and psycho-social wellbeing with being able to communicate effectively. Findings included: Record review of Resident #17's Quarterly MDS assessment dated [DATE] revealed, A [AGE] year old female who admitted [DATE] with Hearing: adequate hearing, Ability to understand others: usually understands - misses some part/intent of message but comprehends most conversations . Makes self-understood: Usually understood- difficulty communicating some…

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.