Windsor Mission Oaks

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 is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #9 ) reviewed for enteral feeding (method to provide nutrition and fluids directly into digestive tract via a feeding tube): LVN Q failed to flush Resident #9's enteral feeding tube per physician's orders. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered. The findings included: Record review of Resident #9's admission Record dated 06/26/2025 revealed a [AGE] year-old man admitted on [DATE] with re-admission on [DATE], with diagnoses which included: Cerebral Infarction (stroke); Dysphagia (difficulty swallowing food or liquids); and Gastrostomy Status (a surgical procedure in which a tube is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours to the State agency for 2 of 9 residents (Residents #1 and #5) reviewed for failure to report. 1. The facility did not report an allegation of misappropriation of property for Resident #1 to the State Agency. 2. The facility did not report an allegation of misappropriation of property for Resident #5 to the State Agency. This failure could place residents at risk of abuse, neglect, or misappropriation of resident property. Findings included: 1. Record review of the admission Record for Resident #1 revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with diagnoses which included: schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by…

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 thoroughly investigate allegations of misappropriation of resident property for 2 of 9 residents (Residents #1 and #5) reviewed for the investigation of allegations. 1) The facility did not investigate when Residents #1 reported an allegation of misappropriation of property. 2) The facility did not investigate when Residents #5 reported an allegation of misappropriation of property. Findings included: 1. Record review of the admission Record for Resident #1 revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] with diagnoses which included: schizoaffective disorder (a chronic mental illness involving symptoms of schizophrenia and characterized by symptoms such as delusions and hallucinations), and multiple fractures of the pelvis. Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident has a a BIMS score of 14, indicating no cognitive impairment. Record review of a facility…

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: 1. [NAME] A was did not wear a facial hair restraint while engaged in food preparation and service. 2. There were ten thermometers in the hand-washing sink. 3. In the reach-in cooler there was a 5-lb. bag of Mozzarella cheese past its use-by date and containers of thickened juice and milk without labels indicating a use-by date. 4. [NAME] B wore a wristwatch on his arm while preparing food in the kitchen. 5. The chemical sanitizing solution in the dish machine did not reach the minimum ppm required. 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 05/05/2024 at 11:20 AM in the kitchen revealed [NAME] A stood in the the kitchen, covered plates of food that were assembled by dietary aides, and placed the trays on carts. [NAME] A had hair approximately 1/4 in length…

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 3 of 3 residents (Residents #43, #79, and #91) reviewed for medications, in that: LVN LL pre-poured medications for Residents #43, #79, and #91 and stored them in the top drawer of the medication cart. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of their medications as ordered. The findings were: 1. Record review of Resident #43's face sheet, dated 5/5/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included Dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities), hypertension (when your blood pressure, the force of blood flowing through your blood vessels, is consistently too high), and Schizoaffective disorder (mental health disorder that is marked by symptoms, such as hallucinations). Record review of Resident #43's Quarterly 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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 5 resident hallways reviewed for environmental conditions ensure in that: The facility failed to ensure four resident hallways did not have hallway side rails that were not clean and sticky to the physical touch. This deficient practice could place residents at risk of living in an unsanitary environment. The findings included: Observation on 5/5/24 from 10:15a.m.,to 10:40 a.m., on the resident 500 hallway revealed that the hallway side rails on both sides of the hallway appeared to be unclean with a noticeable sticky touch to the side rails. The motion of leaning up against the siderails caused the Surveyor-L's pants to stick to the side rail in multiple locations on the hallway. Observation on 5/8/24 from 1:00pm to 1:20 pm with the Housekeeping Director revealed the following: a-the side rail outside of room [ROOM NUMBER]…

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, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 1 building reviewed for pest control. The facility did not have an effective pest control program to eradicate the flies in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns. Findings included: Observation on 05/05/2024 at 10:57 a.m. revealed one fly landed on a laptop while on hall 300 Observation on 05/05/2024 at 11:14 a.m. revealed a fly landing on a person on 400 hall. Record review of Resident #33's face sheet, dated 05/08/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/27/2024 with diagnoses which included: Dementia (decline in cognitive abilities), Hemiplegia(Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure) and, Chronic kidney disease (gradual loss of 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 interview and record review, the facility failed to ensure the staff members were educated on the rights of the resident and the responsibilities of the facility to properly care for its residents for 4 of 22 staff (CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist) reviewed for training requirements in that: The facility failed to ensure four staff which included: CNA N, the Food Service Director, the Physical Therapist, and the Speech Therapist received the required training on resident rights during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the undated facility staff list revealed that CNA N was hired on 7/8/93, the Food Service Director was hired on 8/10/2005, the Physical Therapist was hired on 2/16/2015, and the Speech Therapist was hired on 2/1/2012. During an interview with the Director of Human Resources on 5/7/2024 at 1:00 p.m. she stated that there was not documentation that CNA N, the Food Service…

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 ensure the staff members were educated on abuse, neglect, and exploitation related to resident care for 5 (CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist) of 22 staff reviewed for training requirements in that: The facility failed to ensure that five staff which included: CNA F, the Food Service Director, LVN G, the Occupational Therapist, and the Speech Therapist received the required training on abuse/neglect/exploitation during the year 2023. This deficient practice could place residents at risk of receiving care from staff who were insufficiently trained. The findings included: Record review of the undated facility staff list revealed that CNA F was hired on 4/19/2019, the Food Service Director was hired on 8/10/05, LVN G was hired on 7/14/08, the Occupation Therapist was hired on 4/3/23, and the Speech Therapist was hired on 2/1/2012. During an interview with the Director of Human Resources on 5/7/2024 at 1:00 p.m. she stated that there was not documentation that CNA UU,…

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 4 residents (Resident #94) reviewed for reasonable accommodations and preferences, in that: The facility failed to ensure Resident #94'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 #94's face sheet, dated 5/5/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), HIV [human immunodeficiency virus] (a virus that attacks the body's immune system), and Encephalopathy (means damage or disease that affects the…

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

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 4 resident (Resident #42) reviewed for privacy, in that: CNA C and CNA D did not close Resident #42's window privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #42's face sheet, dated 05/07/2024, revealed an admission date of 03/14/2014 and, a readmission date of 05/10/2021, with diagnoses which included: Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Parkinsonism (Group of neurological conditions that cause difficulty with movement), Hypertension (High blood pressure), Epilepsy (unprovoked recurrent seizures), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Dementia (decline in cognitive abilities), Major depressive disorder (mental disorder characterized by at least two weeks 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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 resident (Resident #29) reviewed for incontinent care, in that: While providing incontinent care for Resident #29, CNA E did not clean between Resident #29's buttocks'' cheeks and CNA E did not use the right technique to clean Resident #29's penis. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #29's face sheet, dated 05/07/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/25/2021, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Hypothyroidism (Under active Thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Liver disease (loss of liver function), Chronic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 4 residents (Resident #29) by 1 of 4 certified staff (CNA E) reviewed for competent staff, in that: 1. While providing incontinent care for Resident #29, CNA E did not clean between Resident #29's buttocks'' cheeks and CNA E did not use the right technique to clean Resident #29's penis. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings included: Record review of Resident #29's face sheet, dated 05/07/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/25/2021, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Hypothyroidism (Under active Thyroid), Hyperlipidemia (Elevated level 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 PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 1 of 4 residents (Resident #70) reviewed for accuracy of medical records in that: The facility failed to ensure Resident's#70 order of Lorazepam 0.5 mg every 4 hours X 2 doses. However, the order did not have a stop date. The findings included: Record review of resident #70 Face sheet dated 5/6/24 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included post-traumatic disorder (a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events, or set of circumstances), Benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous leading to urine obstruction), and anxiety disorder (a disorder that involves…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #29) reviewed for infection control, in that: CNA E did not change her gloves or wash her hands after providing incontinent care for Resident #29 These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #29's face sheet, dated 05/07/2024, revealed an admission date of 05/01/2012 and, a readmission date of 03/25/2021, with diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), Hypothyroidism (Under active Thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Liver disease (loss of liver function), Chronic kidney disease…

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 revealed the facility failed to store, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. Kitchen staff stacked plates that were wet for meal service. 2. Kitchen staff failed to keep the two -compartment oven clean. 3. Kitchen staff failed to store chemicals off the floor. 4. Kitchen staff failed to cover 4 trays of regular diet pumpkin pie dessert plates and 1 tray of puree pumpkin pie dessert cups. 5. The DM and [NAME] O failed to ensure their hairnet covered all of their hair. These deficiencies could affect residents who ate meals prepared from the kitchen and could contribute to the spread of foodborne illness. The findings were: 1. Observation and interview during kitchen tour on 3/28/23 at 9:15 AM revealed a shelving unit beside the steam table on the left side. There were multiple plates and covers stacked that were dripping wet. Interview with the DM confirmed the plates and covers were wet and she instructed one of the dishwashers to place them on 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 ensure residents' right to formulate an advance directive for 1 of 24 residents (Resident #7) reviewed for advanced directives, in that: The facility failed to ensure Resident #7's Out-of-Hospital Do Not Resuscitate (OOHDNR) was signed, by the responsible party, on [DATE] at the bottom of the form. This deficient practice could place residents at-risk for residents' rights not being honored. The findings were: Record review of Resident #7's face sheet, dated [DATE], revealed an re-admission date of [DATE], with diagnoses that included: Alzheimer's disease, heart failure, chronic pain, major depressive, anxiety disorder and insomnia. Record review of Resident 7's quarterly MDS, dated [DATE], revealed a BIMS score of 07, which indicated severe cognitive impairment. Record review of Resident #7's care plan, revision on [DATE], revealed a problem which read, Resident is a DNR. Date Initiated: [DATE]. Revision on [DATE], a goal which read, Facility will…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 residents (Resident #19) whose records were reviewed for falls, in that: Staff failed to identify Resident #19's hoarding behavior as a safety hazard and to implement safety measures. This deficient practice could affect any resident and contribute to avoidable falls. The findings were: Review of Resident #19's face sheet, dated 3/31/23, revealed she was admitted to the facility on [DATE] with diagnoses including Seizure Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, unspecified Psychosis, Obsessive-Compulsive Disorder and Schizoaffective Disorder. Review of Resident #19's quarterly MDS, dated [DATE] revealed Resident #19's BIMS score was 8 (out of 15) reflective of moderate cognitive disorder; she required extensive assistance by 1 person for bed mobility, toileting, transfers, locomotion on and off the unit. Further 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 maintain an effective pest control program for 7 of 24 residents (Residents #8, #12, #21, #52, #75 #108, #115) reviewed for pests, in that: Facility failed to ensure their pest control program was thoroughly working in all areas of the facility This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections. The findings were: 1. Record review of Resident #8's face sheet, dated 03/31/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: paranoid schizophrenia, age-related, physical debility, diabetes type 2, and HIV disease. Record review of Resident #8's annual MDS, dated [DATE], revealed a BIMS score of 08, which indicated moderate cognitive impairment. 2. Record review of Resident #12's face sheet, dated 03/31/2023, revealed the resident was admitted on [DATE] with diagnoses that included: schizoaffective disorder, chronic kidney disorder,…

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 have a right to personal privacy for 1 of 6 resident (Resident #57) reviewed for privacy, in that: CNA A and CNA B did not completely close Resident #57's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #57's face sheet, dated 03/30/2023, revealed an admission date of 02/07/2019, and a readmission date of 04/05/2021, with diagnoses which included: Dementia(loss of cognitive functioning - thinking, remembering, and reasoning), Parkinson's disease (Progressive disorder that affect the nervous system), Type 2 diabetes mellitus(blood glucose, also called blood sugar, is too high.), Chronic kidney disease(gradual loss of kidney function), Chronic obstructive pulmonary disease(a chronic inflammatory lung disease that causes obstructed airflow from the lungs) 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 the interview and record review, the facility failed to transmit the resident assessment within the required time frame for 1 of the 3 discharged residents reviewed for data encoding and transmission. (Resident # 120). The facility did not submit a discharge not anticapated MDS for Resident # 120. This failure could put residents discharged from the facility at risk of not having their assessments transmitted acurately . Findings included: 1.Record review of the face sheet for Resident # 120, dated 3/30/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 12/28/22 with diagnosis that included: [Dementia] (a condition characterized by progressive or persistent loss of intellectual functioning, especially with memory impairment and abstract thinking. [Hypertension] (is blood pressure that is higher than normal) and [Schizophrenia] (is a serious mental illness that affects how a person thinks, feels, and behaves). Record review of discharge MDS dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 28 residents (Residents #48 and, #33) whose assessments were reviewed, in that: 1. Resident #48's Quarterly MDS incorrectly documented the resident as receiving an insulin injection. 2. Resident #33's Quarterly MDS did not indicate he had experienced a significant weight loss. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #48's face sheet, dated 03/31/2023, revealed an admission date of 01/10/2014 and a readmission date of 04/02/2018 with diagnoses that included: Type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), Hypertension(high blood pressure), Hyperlipidemia(blood has too many lipids (or fats), such as cholesterol and triglycerides), Hepatic failure (slow decline in liver function) Record review of Resident #48'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, 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 meet a resident's mental and psychosocial needs for 1 of 6 Residents (Resident #19) whose records were reviewed for care plans. Resident #19's Care Plan did not reflect she was a hoarder affecting her daily living. This deficient practice could affect any resident and contribute to resident needs not being met. The findings were: Review of Resident #19's face sheet, dated 3/23/23, revealed she was admitted to the facility on [DATE] with diagnoses including Seizure Disorder, Anxiety Disorder, Depression, Psychotic Disorder and Schizophrenia. Review of Resident #19's quarterly MDS, dated [DATE] revealed Resident #19's BIMS score was 8 (out of 15) reflective of moderate cognitive disorder. Further review revealed Resident #19 experienced hallucinations and delusions. Review of Resident #19's Care Plan revised on 3/13/23…

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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #57) reviewed for incontinent care, in that: While providing incontinent care for Resident #57, CNA A used a back to front motion to clean Resident #57's genitals. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #57's face sheet, dated 03/30/2023, revealed an admission date of 02/07/2019, and a readmission date of 04/05/2021, with diagnoses which included: Dementia(loss of cognitive functioning - thinking, remembering, and reasoning), Parkinson's disease (Progressive disorder that affect the nervous system), Type 2 diabetes mellitus(blood glucose, also called blood sugar, is too high.), Chronic kidney disease(gradual…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 5 residents (Resident #76) reviewed for hospice services, in that: Facility did not ensure Resident #76's hospice records were a part of their records in the facility This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #76's face sheet, dated 03/31/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: major depressive disorder, lung cancer, chronic kidney disease, 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.