Silver Tree Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status of 1 of 4 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's quarterly MDS assessment dated [DATE] accurately coded to reflect Resident #1's diagnoses of GERD (gastric reflex) and hypothyroidism.The facility failed to ensure Resident #1's quarterly MDS assessment dated [DATE] and Resident #2's assessment were accurate and reviewed and signed by a Registered Nurse before submission. This failure could place residents at risk for not receiving needed care and services to maintain the highest level of well-being. The findings included: Record review of Resident #1's face sheet dated 1/28/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: cerebral infarction (stroke), gastro-esophageal reflux disease without esophagitis (GERD)(reflux of acid from stomach into esophagus resulting in heartburn), 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for care plans: The facility failed to ensure Resident #1's comprehensive care plan was accurate and included the correct diagnoses of hypothyroidism (instead of hyperthyroidism) with appropriate interventions. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:Record review of Resident #1's face sheet dated 1/28/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: cerebral infarction (stroke), gastro-esophageal…

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 clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #2 physician progress notes were obtained by the medical provider and uploaded into the medical record. This failure could affect residents whose records were maintained by the facility and could place them at risk for an incomplete clinical picture and errors in care and treatment. The findings included: Record review of Resident #2's face sheet dated 1/28/2026 revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: acute kidney failure, essential hypertension (high blood pressure), and rheumatoid arthritis (chronic immune disease which attacks the joints causing pain and stiffness). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 13…

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 implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 was transferred with the appropriate number of qualified staff required when using a mechanical lift. This failure could place the residents at risk of injury by not following the resident's care plan and clinical standards of practice. Findings included: Record review of Resident #1's electronic health record reflected a [AGE] year-old female, with an admission date of 04/08/202. Resident #1 had diagnoses which included: Generalized anxiety disorder (excessive persistent worry about everyday things), Muscle wasting and atrophy (thinning or loss of muscle tissue), Rheumatoid arthritis (autoimmune disease causing swelling, pain and stiffness 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 residents (Resident #2 and #3) reviewed for care plans: The facility failed to ensure Residents #2's Care Plan reflected he refused wound treatment prior to 10/01/25. The facility failed to ensure Residents #3's Care Plan reflected her behaviors of making allegations/accusations about resident care.The findings included: Record review of Resident #2's admission record, dated 10/10/25, revealed resident was an [AGE] year-old male resident admitted [DATE] with diagnoses to include protein-calorie malnutrition. Record review of Resident #2's admission MDS assessment, dated 09/11/25, revealed Resident #2's had a BIMS score of 06 out of 15, 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 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 6 residents (Resident #2) reviewed for clinical records. The facility failed to ensure Resident #2's wound treatment was accurately documented from 10/01/25 to 10/06/25. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included:Record review of Resident #2's admission record, dated 10/10/25, revealed resident was an [AGE] year-old male resident admitted [DATE] with diagnoses to include protein-calorie malnutrition. Record review of Resident #2's admission MDS assessment, dated 09/11/25, revealed Resident #2's had a BIMS score of 06 out of 15, indicating severe cognitive impairment. Record review of Resident #2's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (the long-term care medication room) of 2 medication rooms and 1 (Resident #80) of 20 residents reviewed for storage and medication carts. 1. The long-term care medication room was opened without locking. 2. There was one 10 cc syringe of normal saline for flushing Resident #80's PICC line (peripherally inserted central catheter: used to deliver medications and other treatments directly to the large central veins near the heart) on the resident's nightstand unattended. This failure could place residents at risk of misappropriation of medications and using normal saline to different purpose, such as drinking it. The findings were: 1. Observation on 04/17/2025 at 11:53 a.m. revealed the long-term care medication room was unlocked and opened without staff supervision, and inside the medication rooms, there were many over-the-counters and prescribed medication stored.…

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. The facility failed to ensure dietary staff used facial hair restraints properly during meal preparation. The facility failed to ensure the dietary staff used proper hand placement and hand hygiene during plate preparation. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 04/17/2025 at 11:38 a.m. revealed the Dietary Manager while taking food temperatures was wearing a facial hair restraint over the hair on his chin, but not over his mustache. The Dietary Manager continued to cook while not wearing the facial hair restraint properly and was observed stirring soup and onions that were cooking on the stove that would be added to the pork chops. During an observation and interview on 04/17/2025 at 11:45 a.m. the Dietary Manager left the cooking side of the kitchen and when he…

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 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 #37 and #20) of 20 residents reviewed for infection control practices. 1. CNA-M put a new and clean brief under Resident #37 without changing gloves after removing an old and dirty brief. 2. LVN-P changed her gloves without sanitizing or washing her hands after cleaning Resident #20's stoma (small opening in the abdomen that is used to remove body waste) with feces. 3. The facility failed to ensure CNA E and NA F wore the proper PPE when entering Resident #20's room who was isolated due to COVID-19 exposure. These deficient practice could place residents at risk for cross contamination and infections. The findings included: 1. Record review of Resident #37's face sheet, dated 04/18/2025, revealed the resident was 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 interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (CNA G, Dietary Aide K, MA J, Dietary Manager, and ADON A) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured CNA G, Dietary Aide K, MA J, Dietary Manager, and ADON A received required trainings annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for CNA G revealed a hire date of 09/13/2021. Review of a training in-services for CNA G from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for Dietary Aide K revealed a hire date of 11/10/2022. Review of a training in-services for Dietary Aide K from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of ethics training being provided…

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 provide mandatory ethics training for 3 of 27 employees (Dietary Aide K, Dietary Manager, and ADON A) employees reviewed for training, in that: The facility failed to ensure ethics training was provided to Dietary Aide K, Dietary Manager, and ADON A annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for Dietary Aide K revealed a hire date of 11/10/2022. Review of a training in-services for Dietary Aide K from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of Ethics training being provided annually. Record review of the personnel records for Dietary Manager revealed a hire date of 04/17/2023. Review of a training in-services for Dietary Manager from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of ethics training being provided annually. Record review of the personnel records for ADON A revealed a hire date of 02/07/2022. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #82) of 20 residents reviewed the privacy of medical records. RN-H left her computer open with Resident #82's personal and medical information on the nursing cart at the 400-hallway on 04/18/2025. This failure could place residents at risk of resident identifiable and medical information being accessed by unauthorized persons. The findings were: Record review of Resident #82's face sheet, dated 04/18/2025, revealed the resident was [AGE] years old female, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of nonalcoholic steatohepatitis (the accumulation of liver fat), seizures (temporary abnormalities in muscle tome or movement), anemia (blood does not have enough healthy red blood cells and hemoglobin to carry oxygen all through the body), and type 2 diabetes mellitus…

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 assessment accurately reflected the resident's status for 1 of 20 residents (Resident #140) reviewed for assessments: Resident #140's admission MDS, dated [DATE], identified the resident had a urinary indwelling catheter. However, Resident #140's urinary continence was coded to Always incontinence, instead of Not rated, resident had a catcher) in Section H (Bladder and Bowel). This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #140's face sheet, dated 04/18/2025, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnoses of chronic kidney disease-stage 3 (kidneys are less able to filter water and fluid out of the body), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), fluid overload (liquid portion of the blood is too high), dementia (over time…

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 develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission for 1 of 8 residents (Resident #244) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #244. This failure could place residents at risk of not receiving care and services to meet their needs. The findings were: Record review of Resident #244's face sheet, dated 04/15/2025, revealed Resident #244 was admitted on [DATE], with diagnoses which included: acute kidney failure, type 2 diabetes mellitus without complications, hyperlipidemia unspecified, essential (primary) hypertension, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, and personal history of pulmonary embolism. Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to 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 needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #78) reviewed for care plans. The facility failed to ensure Resident #78's care plan reflected the resident's code status. This failure places residents at risk for not receiving proper care and services due to inaccurate care plans. The findings were: Record review of Resident #78's face sheet, dated [DATE], revealed he was admitted on [DATE] with diagnoses which included: malignant neoplasm (also known as a cancerous tumor, is an abnormal growth of cells that can spread to other parts of the body) of unspecified part of unspecified bronchus…

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 was possible for 1 (Resident #65) of 20 residents reviewed for accidents and hazards. The facility failed to ensure Resident #65 did not have a disposable razor in his restroom. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: Record review of Resident #65's face sheet, dated 04/18/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with diagnoses of unspecific protein-calorie malnutrition (reduced availability of nutrients leads to changes in body composition and function), obstructive sleep apnea (intermittent airflow blockage during sleep), chronic kidney disease-stage 3 (kidneys are less able to filter water and fluid out of the body), and obstructive and reflux uropathy (urine cannot drain through the urinary tract). 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 observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #37) of 4 residents reviewed for incontinence care. When CNA-M was providing incontinent care to Resident #37 on 04/16/2025, CNA-M did not separate and clean the resident's labia area. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #37's face sheet, dated 04/18/2025, revealed the resident was [AGE] years old female, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), type 2 diabetes mellitus (the body has trouble controlling blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #37) of 2 residents reviewed for enteral nutrition. When RN-N flushed Resident #37's gastrostomy tube with 250 ml of water, RN-N pushed water inside barrel of syringe with plunger, instead of using gravity. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #37's face sheet, dated 04/18/2025, revealed the resident was [AGE] years old female, originally admitted on [DATE], and re-admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), hemiplegia and hemiparesis (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 ensure parenteral fluids were administered consistent with professional standards for 1 (Resident #80) of 2 resident reviewed for intravenous fluids. RN-O flushed only one lumen for medication port of Resident #80's PICC line (peripherally inserted central catheter: used to deliver medications and other treatments directly to the large central veins near the heart) with 10 cc normal saline when administering evening antibiotic dose. RN-O did not flush the other lumen for blood port of the PICC line, but the physician order said, Flush blood port with 10 cc normal saline every evening antibiotic dose. This failure could affect residents by placing them at risk for blockage of PICC line and blood clots. Findings included: Record review of Resident #80's face sheet, dated 04/18/2025, revealed the resident was an [AGE] year old male and admitted to the facility on [DATE] with diagnoses of pneumonia (infection that inflames air sacs in one or…

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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 (Residents #17 and #80) of 3 reviewed for respiratory care. 1. Resident #17's nebulizer mask was not covered in a plastic bag when it was not used on 04/15/2025. 2. Resident #80 was receiving oxygen 4 liter per minutes via nasal cannular without a physician order. These failures could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following infection control. The findings included: 1. Record review of Resident #17's face sheet, dated 04/18/2025, revealed the resident was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of aphasia (a language disorder that affects a person's ability to communicate), hypertension (high blood pressure), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor 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.

Based on interview and record review, the facility failed to provide communications training for 2 of 27 employees (CNA G and MA J) reviewed for training, in that: The facility failed to ensure effective communication training was provided to CNA G and MA J annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for CNA G revealed a hire date of 09/13/2021. Review of a training in-services for CNA G from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Record review of the personnel records for MA J revealed a hire date of 01/18/2023. Review of a training in-services for MA J from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of communication training being provided annually. Interview with the HR Coordinator on 04/17/2025 at 12:00 PM, revealed the facility used Relias (computer based training program) for employee's annual trainings. The HR Coordinator…

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 provide mandatory effective training on rights of the resident training for 1 of 27 employees (Dietary Manager) reviewed for training, in that: The facility failed to ensure effective rights of the resident training was provided to Dietary Manager annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for Dietary Manager revealed a hire date of 04/17/2023. Review of a training in-services for Dietary Manager from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of resident rights training being provided annually. Interview with the HR Coordinator on 04/17/2025 at 12:00 PM, revealed the facility used Relias (computer-based training program) for employee's annual trainings. The HR Coordinator stated employees received emails informing them they had annual trainings due. The HR Coordinator stated that department heads also received emails when their employees had an annual…

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 CNA received the required minimum 12 hours annual in-service for 1 of 4 CNAs (CNA G) reviewed for training. The facility failed to provide the required 12 hours of annual training to CNA G. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for CNA G revealed a hire date of 07/31/2023. Review of a training in-services for CNA G from the previous 12 months, provided by the HR Coordinator revealed no evidence that the facility provided the required 12 hours of in-service trainings including communication training being provided annually. Interview with the HR Coordinator on 04/17/2025 at 12:00 PM, revealed the facility used Relias(computer-based training program) for employee's annual trainings. The HR Coordinator stated employees received emails informing them they had annual trainings due. The HR Coordinator stated that department heads also received emails when their employees had an annual…

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 provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71 for 1 of 27 (Dietary Manager) employees reviewed for training, in that: The facility failed to ensure behavioral health training was provided to Dietary Manager annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings include: Record review of the personnel records for Dietary Manager revealed a hire date of 04/17/2023. Review of a training in-services for Dietary Manager from 04/15/2024 to 04/15/2025, provided by the HR Coordinator revealed no evidence of behavior health training being provided annually. Interview with the HR Coordinator on 04/17/2025 at 12:00 PM, revealed the facility used Relias (computer-based training program) for employee's annual trainings. The HR Coordinator stated employees received emails informing them they had annual trainings due. The HR Coordinator stated that department heads also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #6) reviewed for abuse. The facility failed to ensure residents were free from verbal abuse on 01/17/2024 when CNA L spoke in a negative manner about a resident at a high volume while in a resident hallway outside of a resident room. This failure could place residents at risk for abuse, trauma, and psychosocial harm. The findings included: Record review of Resident #6's face sheet reflected a [AGE] year-old resident with an admission date of 06/11/2024 and diagnosis including cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery (a type of stroke that occurs when blood flow to the brain is disrupted), type 2 diabetes mellitus (a chronic disease in which the body has trouble controlling blood sugar and using it for energy), and hemiplegia (paralysis…

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 residents had the right to be free of misappropriation of resident property and exploitation for 1 of 4 residents (Resident #7) reviewed for misappropriation and exploitation. The facility did not prevent misappropriation when CNA M and/or CNA N stole Resident #7's bank card and began using it at the facility vending machine, as well as various grocery stores, convenience stores, and restaurants around the facility. This failure could place residents at risk of misappropriation of money, possessions, and feelings of loss. The findings included : Record review of the facility provider investigation report written by the facility administrator, dated 07/25/2024, reflected: [Resident #7] is an [AGE] year-old woman who resided at the facility for long term care services. [Resident family member] reached out to facility letting the facility know that [Resident #7]'s credit card was being used at the facility vending machines as well as around town…

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 ensure all drugs and biologicals were stored in locked compartments for 1 of 2 nursing carts (400-hall nursing cart) reviewed for storage. The facility failed to ensure the 400-hall nursing cart was locked when left unattended. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: During an observation on 01/17/2025 at 12:15 p.m. revealed the 400-hall nursing cart was found unlocked and unattended on the 400 hallway. This state surveyor was able to open all drawers revealing multiple medication blister packs, scissors, and bottles of medications. Interview on 01/17/2025 at 12:19 p.m. with LVN-A stated the 400-hall nursing cart was unlocked and unattended on the 400 hall. LVN-A stated she did not realize she left the cart unlocked. LVN-A stated it was important the nursing cart was locked at all times due to resident, visitor, and staff safety. LVN-A stated by the nursing cart being unlocked, anyone…

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 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 1 Residents (Residents #1) of 3 residents reviewed for infection control. The wound care nurse LVN-B entered Resident #1's room, who was on EBP, on 01/15/2025 at 9:00 a.m., and failed to put on a gown when the nurse performed wound treatment for Resident 1. These deficient practices affect residents who require direct care and could place residents at risk for cross contamination and infections. The findings were: Record review of Resident #1's electronic face sheet, dated 01/17/2025, reflected he was [AGE] years old male, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses included: Parkinson disease (movement disorder of the nervous system that worsen over time), dermatitis (swelling and irritation 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 maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #'1's electronic medical record did not contain complete and accurate documentation that resident received the scheduled administration of oxycodone (a medication use to treat pain) on 6/10/24. This failure could result in residents' records not accurately documenting the administration of medications and could result in a decline in heath. The findings include: Record review of Resident #1's face sheet, dated 06/14/24, revealed a [AGE] year-old female resident who was admitted on [DATE] with diagnoses that included: end stage renal disease, anxiety, metabolic encephalopathy (brain disease), osteo (bone disease), HTN (hypertension). Resident was her own RP. Record review of Resident #1's admission MDS dated [DATE] revealed 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.

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. The facility failed to ensure dietary staff were wearing beard restraints who had facial hair. The facility failed to ensure dietary staff used proper hand hygiene during meal service. The facility failed to ensure dietary staff properly handled soup bowls while serving soup. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 03/04/2024 at 10:07 a.m. revealed [NAME] E with a thin mustache and beard to his chin with hair approximately ½ inch to an inch long not wearing beard guard or beard restraint. When asked about his beard [NAME] E stated Oh and went to go find the beard guards placing a hair restraint on his face. [NAME] E further stated the reason for wearing a beard guard was so hair wouldn't go into the food. [NAME] E stated it could cause bacteria 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, interviews, and record reviews, 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 3 Residents (Residents #24, #43, and #63) of 16 residents reviewed for care plans, in that: 1.Resident #24's comprehensive care plan revised dated 01/24/2024 did not reflect she was incontinent of bowel. 2.Resident #43's comprehensive care plan revised dated 05/25/2021 did not reflect she was incontinent of bowel. 3. Resident #63's comprehensive care plan did not reflect that her diet was regular, mechanical soft texture, limit oranges, bananas, potatoes, and tomatoes which was ordered on 02/16/2024. The care plan inaccurately reflected she was on a other than regular diet. These deficient practices could place residents at risk of not…

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 reasonable accommodation of resident needs for 2 of 8 resident rooms (Resident #49 and #68) reviewed for call lights. The facility failed to ensure Residents #49 on 03/05/2024 and #68's on 03/04/2024 call lights were within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed. Findings included: Record review of Resident #68's face sheet, dated 03/07/2024, revealed the resident was originally admitted to the facility on [DATE] and admission date 02/06/2024 with diagnoses which included: paroxysmal atrial fibrillation, hypotension, hypothyroidism, hyperlipidemia, essential hypertension, depression, pain in unspecified joint, type 2 diabetes mellitus with unspecified complications and repeated falls. Record review of Resident #68's Medicare 5-day MDS assessment, dated 02/12/2024, revealed the resident's BIMS score was 8, which indicated moderate cognitive…

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 record review and interview, the facility failed to assess each resident quarterly using the Minimum Data Set form specified by the state and approved by CMS for 1 of 8 residents (Resident 58) reviewed for quarterly assessments. Resident #58's quarterly MDS Assessment was not completed within 92 days of the previous MDS assessment. This failure could place residents at-risk of not having their assessments completed timely. The findings included: Record review of Resident #58's face sheet, dated 03/07/2024, revealed the resident was originally admitted to the facility on [DATE] and an admission date 03/29/2023 with diagnoses which included: encounter for other orthopedic aftercare, fracture of unspecified part of neck of right femur, history of falling, type 2 diabetes mellitus without complications, hyperlipidemia, essential hypertension, other chronic pain, major depressive disorder, presence of left artificial knee joint, ileus, and neuromuscular dysfunction of bladder. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 residents of 24 (Residents #43 and #63) residents reviewed for MDS assessments, in that: 1. Facility failed to ensure Resident #43's quarterly MDS assessment with an ARD of 01/23/2024, assessment accurately reflected her bladder status. 2. Facility failed to ensure Resident #63's annual MDS assessment with an ARD of 02/20/2024, accurately reflected her oxygen therapy and her mechanical soft diet. These deficient practices could place residents at risk of inadequate care. The findings included: 1. Record review of Resident #43's electronic face sheet, dated 03/06/2024, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: unspecified sequelae of cerebral infarction (unspecified symptoms and signs involving cognitive functions following cerebral infarction (area of necrotic tissue in brain following lack 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 observations, interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 residents (Residents #45 and #57) of 24 residents reviewed for comprehensive care plans, in that: 1.Resident #45's comprehensive care plan revised date 02/11/2024 was not updated to reflect he no longer had an indwelling urinary catheter which was removed on October of 2023. 2. Resident #57's comprehensive care plan revised date 04/05/2023 was not updated to reflect his MASD which was noted in his quarterly MDS assessment with an ARD of 12/24/2023. These deficient practices place residents at risk of missed or miscommunicated care. The findings included: 1. Record review of Resident #45's electronic face sheet dated 03/05/2024 reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: cellulitis 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, interviews and record reviews, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 resident (#78) of 1 reviewed for enteral care. LVN K failed to check the placement of Resident #78's placement of the tube by aspiration of contents, did not flush with 5-10 ml of water between the two medications he administered and did not stop the continuous feeding for 30 minutes prior to medications being administered on 03/05/2024 These deficient practices could place residents at risk for aspiration pneumonia, bloating discomfort and malabsorption of medications administered. The findings included: Record review of Resident #78's electronic face sheet dated 03/06/2024 reflected she was originally admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 2 of residents (Resident #63 and #190) reviewed for respiratory care. 1. Facility failed to ensure Resident #63's oxygen was administered at the prescribed rate on 03/04/2024 and 03/05/2024. 2. Facility failed to ensure Resident #190 who used oxygen had physician orders for oxygen administration. This facility failure could result in residents receiving inadequate treatment. Findings included: 1. Record review of Resident #63's face sheet dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing and fatigue), zoster (a viral infection that occurs with reactivation of the varicella-zoster virus, usually results in a painful…

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 ensure the safe and secure storage of drugs and biologicals for 1 of 8 medication carts observed for mediation storage in that: On 03/06/2024 a medication cart was left unlocked and unattended beside the nurse's station at the end of 800 hall. This deficient practice could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel. Findings include: Observation on 03/06/2024 at 5:50 PM revealed a medication cart by the nurse's station at the end of 800 hall was unattended and unlocked for approximately 5 minutes. There were no staff observed at the nurse's station or the surrounding area, only residents. Interview with MA H on 03/06/2024 at 5:56 PM revealed she went into the dinning room to give medications to a resident and forgot to lock the medication cart. MA H stated that the policy was that all medications are put away and the medication cart and computer are to be locked before leaving the medication cart unattended. MA H stated it was important to lock…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to prepare food in a form to meet individual needs for 1 of 24 residents (Resident #63) observed for dietary needs. Facility failed to serve Resident #63 on 03/06/2024 the prescribed diet of regular, mechanical soft texture and served her regular with regular texture. This deficient practice places residents at risk for choking or malnutrition. The findings included: Record review of Resident #63's face sheet dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing and fatigue), zoster (a viral infection that occurs with reactivation of the varicella-zoster virus, usually results in a painful but self-limited dermatological rash) without complications, sepsis (severe infection) due to Methicillin Resistant Staphylococcus Aureus (staph…

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 on each resident that were accurately documented for 2 of 24 residents (Residents #63 and #71) reviewed for accurate medical records in that: 1. RN L initialed off that Resident #63's oxygen was infused at 1-2 l/min, when it was at 3L/min , and she had not checked the rate on 03/04/2024 and 03/05/2024. 2. LVN M did not initial off for treatments for Resident #71 on his TAR for wound care on 03/01/2024, 03/02/2024 and for both treatments on 03/04/2024. This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided. The findings included: 1. Record review of Resident #63's face sheet dated 03/04/2024 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: acute diastolic congestive heart failure (damage to the heart and symptoms come on suddenly, often sudden difficulty breathing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to 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 1 Resident (#43) of 5 residents reviewed for infection control in that: CNA I failed to sanitize his hands after he changed gloves when he emptied Resident #1's urine container, wiped with the same wipe, same area several times, placed a clean brief onto Resident #1's bed with soiled gloves on and did not sanitize his hands or change gloves throughout the whole procedure of incontinent care to include after wiping feces from the residents anal area on 03/06/2024. This facility failure affects residents who need assistance with ADL's and could result in cross contamination and spread of infections. The findings included: 1.Record review of Resident #43's electronic face sheet, dated 03/06/2024, reflected she was…

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

Based on 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 3 residents (Resident #1) reviewed for infection control. While providing incontinent care for Resident #1, CNA A did not sanitize her hands between glove changes, and picked up a clean incontinent brief with soiled gloves and placed it under Resident #1. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #1's face sheet, dated 02/01/2024, reflected an admission date of 12/05/2023. His diagnoses included: ataxia (without coordination, loss of muscle control in arms and legs), dysphagia (difficulty swallowing), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), type 2 diabetes mellitus (high level of sugar in the 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 interviews and record reviews, the facility failed to maintain medical records on each resident that are complete and accurately documented for 2 (Resident #1 and Resident #3) out of 8 residents reviewed for clinical documentation in that: 1. Resident #1's pressure sore documentation by NP C was inaccurate. 2. Resident #3's treatments were not documented on the TAR by LVN F for September 16th, 2023. These facility failures could affect residents by receiving inaccurate care provided or ordered. The findings were: 1.Record review of Resident #1's electronic face sheet dated 12/21/2023 reflected she was originally admitted to the facility on [DATE], readmitted on [DATE] and recently admitted on [DATE]. Her diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), displaced comminuted fracture of shaft of left femur (the bone of the thigh has broken into three or more pieces), hemiplegia (severe or complete loss of strength or…

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 that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1(Resident #4) of 3 residents reviewed for oxygen therapy in that: The facility failed to acquire oxygen orders for Resident #4 until 5 days after she was readmitted on oxygen. This facility failure could result in residents missing or receiving inadequate treatment. The findings included: Record review of Resident #4's electronic face sheet dated 12/19/2023 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE] after she was hospitalized for respiratory difficulty on 12/03/2023 where she was diagnosed with COVID-19. Her primary diagnoses included: seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tome or movements, behaviors sensations or states 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, 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 1 (Resident #2) of 5 residents reviewed for infection control in that: CNA A failed to sanitize her hands after removing soiled gloves and putting on clean gloves during incontinent care performed for Resident #1. This facility failure could result in cross contamination and spread of infections. The findings included: Record review of Resident #2's electronic face sheet dated 12/20/2023 reflected she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: unilateral primary osteoarthritis (a chronic condition affecting the joints. Causes pain and inflammation), right knee, altered mental status (a change in mental function that stems from illnesses, disorders 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.