Sunny Springs Nursing & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents environment remained free of accident hazards for 1 of 26 residents (Residents #11) reviewed for accident hazards. The facility failed to ensure a safe environment to prevent accidents and hazards for Residents #11 by not ensuring 3 razors (1 razor that did not have a cover over the blades and 2 razors in the open package) in his drawer were stored securely. This failure could place residents at risk for injuries. Findings included: Record review of Resident #11's face sheet dated 09/10/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses legal blindness, high blood pressure, malignant neoplasm of the prostate (prostate cancer), and depression. Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated he usually understood others and usually made himself understood. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 2 residents reviewed for nutritional status (Resident #12). The facility failed to ensure Resident #12's enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) was administered as ordered by the physician on 09/08/25. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life.Findings included: Record review of Resident #12's face sheet dated 09/10/25, indicated a [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) and gastrostomy status (surgical opening in stomach to provide nutrition and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 had a physician's order for oxygen. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included: Record review of Resident #1's face sheet, dated 09/10/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included shortness of breath also known as SOB, (feeling of difficulty breathing or not being able to get enough air), obesity, depression (sadness), diabetes, and Chronic obstructive pulmonary disease, also known as COPD (a group of lung diseases…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 6 residents (Resident #42) reviewed for pharmacy services. The facility failed to ensure Resident #42 did not have duplicate orders for his potassium. This failure could place the residents at risk of not receiving the intended therapeutic benefits of prescribed medications.Findings included: Record review of Resident #42's face sheet dated 09/10/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia (memory loss) and hypertension (high blood pressure). Record review of Resident #42's annual MDS assessment dated [DATE], indicated he was usually understood and usually understood others. Resident #42 had a BIMS score of 15, which indicated his cognition was intact. Record review of Resident #42'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 review, the facility failed to provide food and drink that accommodated the residents' preferences for 1 of 23 residents (Resident #1) reviewed for preferences. The facility did not honor Resident #1's preference for two milks with her breakfast on 09/09/25 and 09/10/25. This failure could result in a decrease in resident choices. Findings included: Record review of Resident #1's face sheet, dated 09/10/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included shortness of breath also known as SOB, (feeling of difficulty breathing or not being able to get enough air), obesity, depression (sadness), diabetes, and Chronic obstructive pulmonary disease, also known as COPD (a group of lung diseases that cause airflow obstruction and breathing problems. Record review of Resident #1's quarterly MDS assessment, dated 08/20/25, indicated Resident #1 understood and was understood by others. Her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 1 of 6 residents (Resident #3) reviewed for abuse. The facility did not implement the policy on investigating an injury of unknown origin to the state agency for Resident #3 when Resident # 3 was found with bruising and a skin tear on 02/11/2025 on the left arm. This failure could place the residents at increased risk of abuse and neglect. Findings included: Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), and depression…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 6 residents (Resident #3) reviewed for abuse and neglect. The facility staff did not report to the state agency that Resident #3 had a bruise and a skin tear to the left arm of unknown origin on 02/11/25. This failure could place the residents at increased risk for abuse and neglect or further potential abuse due to unreported allegations of abuse and neglect. Findings included: Record review of Resident #3's face sheet, dated 04/09/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (diseases that affect memory, thinking, and the ability to perform daily activities), diabetes (is a chronic…

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 develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 4 (Resident #1 and Resident #2) residents reviewed for the care plan. 1. The facility failed to ensure urinalysis results on 04/05/2025 for Resident #1's contact isolation was care planned on 04/06/2025 for a diagnosis of Extended-Spectrum Beta-Lactamase, also known as ESBL (a bacteria that can be spread from person to person on contaminated hands of both patients and healthcare workers. 2. The facility failed on 04/03/2025 to ensure Resident #2's contact isolation was care planned for methicillin-resistant Staphylococcus aureus also known as MRSA (an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections) and for her refusal to stay in her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure LVN D wore the proper PPE (gown and gloves) while checking Resident #1's blood sugar or administering insulin on 04/08/25, who was positive for ESBL. The facility failed to ensure CNA E wore the proper PPE (gown and gloves) while providing care to Resident #1, who was positive for ESBL on 04/09/25. The facility failed to ensure Resident #2 understood contact isolation precautions when the resident was in activities with other residents and positive for MRSA on 04/08/25. These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others 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 interviews, and record review the facility failed to ensure residents were free from abuse for 3 of 13 residents (Resident #1, #2 and Resident #3) reviewed for resident abuse. 1. The facility did not ensure Resident #1 was free from abuse when Resident #3 struck Resident #1 on the shoulder 11/8/24. 2. The facility did not ensure Resident #2 was free from abuse when Resident #4 reached out and grabbed Resident #2 under the arm on 12/9/24. 3. The facility did not ensure Resident #3 was free from abuse when Resident #5 pushed Resident #3 head on 12/9/24. The noncompliance was identified as PNC. The past noncompliance began on 11/8/24 and ended on 12/14/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Resident #1 Record review of Resident #1's face sheet, dated 11/12/24, reflected Resident #1 was an [AGE] year-old female, admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Residents #7) reviewed for pharmacy services. 1. The facility did not ensure Resident #7 medications were administered during the scheduled time. 2. The facility did not ensure Resident #7 was given Estrace Vaginal Cream 0.01 mg/gm as scheduled. 3. The facility did not ensure Resident #7 was given Vitamin B-12 2000 mcg. These failures could place the residents at risk of not having medications available for use, drug diversion, not receiving their medications as ordered, and exacerbation of their disease processes. Findings included: 1. Record review of Resident #7's face sheet, dated 01/28/25, reflected Resident #7 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory,…

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 the assessment accurately reflected the resident's status for 2 (Resident #64, and Resident #78) of 24 residents reviewed for accuracy of MDS assessments. 1) The facility failed to ensure that Resident #64's MDS accurately reflected the resident had received antibiotics during the 7-day look back period. 2) The facility failed to ensure that Resident's #64's MDS accurately reflected the resident had a MRSA infection to his right hip. 3) The facility failed to ensure Resident #78's MDS accurately reflected his discharge from the facility. These failures could put residents at risk of not receiving the necessary care and services related to inaccurate MDS assessment. Findings included: 1) Record review of Resident #64's face sheet dated 08/20/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of depression (common but serious mood disorder causing sadness), centrilobular emphysema (a form of lung…

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

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 (08/21/24 and 08/22/24) of 2 days reviewed for quality of life. The facility failed to ensure 4 of 8 scheduled activities were provided according to the August 2024 activity schedule on 08/21/2024 and 08/22/2024. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of the Activity Calendar dated August 2024 indicated the following: Wednesday 08/21/2024: 09:30 AM balloon tennis; 10:30 AM Left-Right-Center game; 2:30 PM bean bag toss; 03:30 PM Help Your Neighbor Thursday 08/22/2024: 09:30 AM ball toss; 10:30 AM Left-Right-Center game; 02:30 PM Dominoes; 03:30 PM Skip Bo. During an observation on 08/21/2024 at 02:35 PM, the bean bag toss activity was not happening in the dining…

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 had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #179) reviewed for resident rights. The facility failed to obtain informed consent based on the information of the benefits and risks for Resident #179 before administering Bupropion HCL ER (Wellbutrin - a medication used to treat depression). This failure could place residents at risk of receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status. Findings included: Record review of Resident #179's face sheet, dated 08/22/24, indicated a [AGE] year-old male who was admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consult with the resident's physician immediately when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 of 24 residents (Resident #33) reviewed for resident rights. The facility failed to notify Resident #33's physician when he refused his ordered lab draws for 4 weeks. This failure placed residents' physician at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of Resident #33's face sheet dated [DATE], indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #33 had diagnoses of end stage renal disease (when the kidneys no longer adequately filter waste products from the blood and function less than 15 percent of normal levels), diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 (Resident #57) of 4 residents reviewed for resident rights The facility failed to ensure the ADON logged out of her computer and protected the privacy of Resident #57's Medication Administration Record. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others. Findings included: Record review of Resident #57's face sheet, dated 08/22/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included stroke, diabetes, and high blood pressure. Record review of Resident #57's quarterly MDS assessment, dated 06/13/24, indicated Resident #57 understood and was understood by others. Resident #57's BIMS score was 10, which meant she was moderately cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 24 residents (Resident #10) reviewed for abuse. The facility failed to follow their policy to report neglect to HHSC when Resident #10's Family Member alleged that CNA C left Resident #10 in bed beyond soiled, and shaking and CNA C stated, I don't fool with her because she hits me. This failure could place residents at risk of abuse, neglect, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's policy titled, Abuse Prevention and Prohibition Program revised October 24, 2022, indicated: Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property .IX. Reporting/Response .D. The facility will report allegations of abusee, neglect, injuries of unknown source, misappropriation of resident property .i. Immediately or no…

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 after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 24 residents (Residents # 10) reviewed for abuse and neglect. The facility failed to report the allegation of neglect for Resident #10 to the State Agency within required reporting timeframes, within 24 hours 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 24 residents (Residents #64) reviewed for care plans. The facility failed to develop a care plan for Resident #64's diagnosis of MRSA (methicillin-resistant staphylococcus aureus) infection to the wound on his right hip. This failure could have placed resident at risk for not having their needs met. The findings included: Record review of Resident #64's face sheet dated 08/20/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of depression (common but serious mood disorder causing sadness), centrilobular emphysema (a form of lung disease in people who smoke that affects the upper lungs), anxiety (a feeling of nervous, restless, or tense),…

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 that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 1 oxygen cylinders reviewed for respiratory care. The facility failed to ensure an oxygen cylinder was stored properly. This failure could place residents and staff at risk for accidents, leaks, and damage to the cylinder. The findings included: During an observation on 08/21/24 at 4:00 p.m. revealed an unsecured oxygen cylinder at the nurse's station. During an observation and interview on 08/21/24 at 4:21 p.m., revealed LVN B looked at the oxygen cylinder unsecured at the nurses' station. LVN B said she was unaware that the oxygen cylinder was at the nurse's station. She said it was one of the residents who went out to smoke. She said the oxygen cylinders should always be secured. During an interview on 08/21/24 at 5:25 p.m., the Activity Director said she was the person who set the oxygen cylinder at the nurses' station. She said she was aware that the oxygen cylinder…

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 dialysis services were provided consistently with professional standards of practice for 1 of 1 resident (Resident #33) reviewed for quality of care. The facility failed to ensure Resident #33 had a physician's order for dialysis treatment. The facility failed to monitor Resident #33's dialysis catheter. These failures could place the residents, who received dialysis, at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #33's face sheet dated 08/21/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #33 had diagnoses of end stage renal disease (when the kidneys no longer adequately filter waste products from the blood, function less than 15 percent of normal levels), diabetes mellitus type 2 (a group of diseases that affect how the body uses blood sugar), dependence on renal dialysis (process of removing…

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 each resident's drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring or side effects) for 1 (Resident #179) of 5 residents reviewed for unnecessary meds. 1. The facility failed to ensure Resident #179 had behavior monitoring for Bupropion HCL ER(Wellbutrin) and Sertraline (Zoloft) used for depression. 2. The facility failed to ensure Resident #179 had side effect monitoring for Clonazepam (Klonopin) used for anxiety. These failures could place residents at risk of possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of Resident #179's face sheet, dated 08/22/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included Spinal stenosis (pain in the lower back, that can cause cramping in one or both legs), Schizophrenia (a…

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

Based on observation and interview the facility failed to ensure all drugs were only accessible by authorized personnel for 1 of 4 medication carts (hall 100). The facility did not ensure the 100 hall medication cart was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk of not receiving drugs and biologicals as needed and a drug diversion. Findings included: During an observation and interview on 08/20/24 at 12:10 p.m., the 100-hall medication cart was left unlocked, and staff, residents, and visitors were observed walking by the unlocked medication cart. The ADON exited a resident's room and said she was responsible for leaving the cart unlocked. She said she was in a hurry and forgot to lock her cart. The ADON said it was her responsibility to lock the cart when unattended. The ADON said by leaving the cart unlocked and unattended, anyone could open the cart and take medications. During an interview on 08/22/24 at 12:15 p.m., LVN B said the medication cart should never be left open when unattended. She said the medication cart…

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 3 of 4 residents (Residents #38, #31 and #8) reviewed for hospice services. The facility failed to obtain Resident #38's most recent plan of care, hospice election form, physician certification, and hospice medication list. The facility failed to obtain Resident #31's most recent updated hospice plan of care and hospice medication list. The facility failed to ensure Resident #8's hospice medication orders reflected what Resident #8 was currently receiving at the facility. These deficient practices could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation,…

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 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 #64) of 24 residents reviewed for infection control practices and transmission-based precautions. 1) The facility failed to ensure Resident #64 was placed on (TBP) transmission-based isolation for MRSA infection to his right hip wound. 2) The facility failed to ensure CNAs received proper notification about the infection. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. Findings included: 1) Record review of Resident #64's face sheet dated 08/20/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of depression (common but serious mood disorder causing sadness),…

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 follow their own established smoking policy for 1 of 4 residents (Resident #9) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #9. This failure could place residents at risk of unsafe smoking and injury. Findings included: Record review of Resident #9's face sheet, dated 8/22/24 indicated Resident #9 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included stroke and high blood pressure. Record review of Resident #9's quarterly MDS assessment, dated 07/04/24, indicated Resident #9 was usually understood and usually understood by others. Resident #9's BIMs score was 15, which indicated he was cognitively intact. Resident #9 required limited assistance with bathing and set-up assistance with toileting, personal hygiene, transfer, eating, and bed mobility. Record review of Resident #9'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 interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 16 residents reviewed for pharmacy services. (Resident #1) The facility failed to ensure RN F, CMA G, and LVN C were able to account for the missing 30 count card of Resident #1's Hydrocodone-Acetaminophen 7.5-325mg tablet used for pain management. This failure could place residents at risk for decreased quality of life, misappropriation of property, misappropriation of physician ordered medications and dignity. Findings included: Record review of Resident #1's face sheet dated 07/11/24 indicated she was an [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses chronic obstructive pulmonary disease (a progressive lung disease characterized by long-term respiratory symptoms and airflow…

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 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 2 residents (Resident #9) reviewed for hospice services. The facility failed to ensure Hospice Aide A performed a proper transfer when she failed to use a mechanical lift, as ordered by the physician and per Resident #9's care plan, to transfer Resident #9 from her wheelchair to her bed on 07/15/2024. This failure could place residents at risk for falls, injuries, and a decreased quality of life. Findings included: Record review of a face sheet dated 07/11/2024 indicated, Resident #9 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #2) reviewed for infection control. 1. The facility failed to ensure CNA D performed hand hygiene when she changed gloves while providing perineal care for Resident #2. This failure could place residents and staff at risk for cross contamination and the spread of infection. Findings included: 1.Record review of Resident #2's face sheet dated 07/11/24 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses dementia(a syndrome characterized by a general decline in cognitive abilities that affects a person's ability to perform daily tasks), high blood pressure, chronic obstructive pulmonary disease (a progressive lung disease characterized by long-term…

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, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and Resident #2) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1 and Resident #2's restorative care program was included in their comprehensive care plans. These failures could place the residents at risk of not having their individual needs met, not receiving necessary services, and a decreased quality of life. Findings included: 1. Record review of a face sheet dated 06/17/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included muscle weakness, unsteadiness on feet, reduced mobility, and difficulty walking. 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 provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 2 of 4 residents (Resident #1 and Resident #2) reviewed for range of motion. The facility failed to ensure CNA A provided restorative care to Resident #1 and Resident #2 according to their Nursing Restorative Care Program plan of care. These failures could place residents at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: 1. Record review of a face sheet dated 06/17/2024 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included muscle weakness, unsteadiness on feet, reduced mobility, and difficulty walking. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood and usually understood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #1 and Resident #2) reviewed for infection control practices in that: CNA B did not ensure Resident #1 was cleansed of stool when she (CNA B) performed incontinent care. CNA C did not ensure Resident #2 was cleansed of stool when she (CNA C) performed incontinent care. CNA C did not remove her dirty gloves, perform hand hygiene (wash her hands or use hand sanitizer) and place clean gloves on before grabbing Resident #2's draw sheet during incontinent care. These failures could place residents at risk for cross contamination and infections. Findings included: 1.Record review of the face sheet dated 10/31/23 indicated Resident #1 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses…

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 free of accident and hazards for 1 of 3 residents (Resident #1) reviewed for accident hazards in that: CNA D did not ensure Resident #1's bed was locked after providing care. This failure could place dependent residents at risk for falls, injuries and decreased quality of life. Findings included: 1.Record review of the face sheet dated 10/31/23 indicated Resident #1 was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including, arteriovenous malformation of digestive system vessel ( a tangle of blood vessels that irregularly connects arteries and veins) vascular dementia, muscle weakness, unspecified abnormalities of gait and mobility, high blood pressure, type 2 diabetes, heart disease, and history of urinary tract infection. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 5 of 19 residents (Resident #16, Resident #19, Resident #21, Resident #40, and Resident #75) reviewed for environment. The facility failed to repair deep scrapes that exposed the sheetrock on the wall behind the head of the bed and on the wall next to the bed for Resident #16, Resident #19, Resident #21, and Resident #40. The facility failed to ensure Resident #75's bed linens were changed. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 07/14/2023 indicated Resident #16 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, unspecified severity, without behavioral (loss of memory, language, problem solving and other thinking abilities that were severe enough 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 interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #9 and #129) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #9 and #129 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: 1. Record review of Resident #9's face sheet, dated 07/12/2023, indicated Resident #9 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement written policies that prohibit and prevent abuse, neglect, and exploitation for 1 of 19 (Resident #4) residents reviewed for abuse and neglect. The facility did not implement their abuse and neglect policy and procedure when the staff did not report Resident #4's bruises of unknown source to the abuse coordinator. This failure could place the residents at increased risk for abuse and neglect. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack, hypertension (high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 19 residents (Resident #4) reviewed for abuse and neglect. The facility did not ensure facility staff reported bruising of unknown origin for Resident #4 to the abuse coordinator (Administrator). This failure could place the residents at increased risk for abuse and neglect. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects…

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 the baseline care plan within 48 hours of admission for 1 of 3 residents (Resident #75) reviewed for baseline care plans. The facility failed to ensure Resident #75 had a baseline care plan completed within 48 hours of admission This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due to a loss of oxygen to the area caused by a blood clot), and type 2 diabetes mellitus with diabetic neuropathy,…

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 develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 13 residents reviewed for care plans. (Resident #4) The facility did not implement Resident #4's care plan related to anticoagulant therapy. This failure could place residents at risk for inaccurate care plans and decreased quality of care. The findings included: Record review of the face sheet, dated 07/11/23, revealed Resident #4 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness, or slowing of movement), unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), history of cerebral infarction (stroke), history of a heart attack,…

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 the comprehensive care plan was reviewed by the interdisciplinary team and that the resident was invited to participate in developing the care plan and making decisions about his or her care for 1 of 19 residents (Resident #75) reviewed for care plan timing and revision. The facility failed to ensure Resident #75 was invited to participate in the development and review of his care plan. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis), cerebral infarction due to embolism of unspecified cerebellar artery (damage to tissues in the brain due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 3 residents (Resident #54 and Resident #75) reviewed for respiratory care. 1. The facility did not ensure Resident #54 had a physician's order for oxygen that she wore continuously. 2. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #75. These failures could place residents who receive respiratory care at risk for developing respiratory complications. The findings included: 1. Record review of the face sheet, dated 07/11/2023, revealed Resident #54 was an [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of chronic respiratory failure with hypoxia (not enough oxygen in the blood), shortness of breath, and COPD - chronic obstructive respiratory disease (chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 residents (Resident #75) reviewed for dialysis. The facility failed to have physician's orders for the care of Resident #75's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access). The facility failed to care plan Resident #75's central venous catheter used for dialysis. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of a face sheet dated 07/11/2023, indicated Resident #75 was a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 13 residents reviewed (Resident #4) for anticoagulant monitoring and skin assessments. 1. The facility did not ensure the physician orders for anticoagulant monitoring on Resident #4 were adequately followed, when Resident #4 had an increase in bruising while taking an anticoagulant medication (blood thinner that works by preventing red blood cells from forming clots). 2. The facility did not ensure LVN L, who was the treatment nurse, accurately performed weekly skin assessment's resulting in no documentation of Resident #4's bruising. These failures could place residents at an increased risk for bleeding, bruising, and not receiving the care and services to meet their individual needs. The findings included: Record review of the face sheet,…

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 2 residents (Resident #68) reviewed for hospice services. The facility did not ensure Resident #68'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 a face sheet dated 07/11/2023, indicated Resident #68 was a [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included severe protein-calorie malnutrition…

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 diseases and infections for 1 of 6 staff (NA H) reviewed for infection control. The facility did not ensure NA H performed hand hygiene while providing incontinent care to Resident #26. The facility did not ensure NA H cleaned Resident #26 peri-anal area before placing a clean brief underneath her. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: During an observation on 07/11/2023 at 1:50 p.m., NA H and CNA K provided incontinent care to Resident #26. NA H and CNA K performed hand hygiene and put on gloves. NA H unfastened Resident #26's brief. NA H cleaned Resident #26's front peri area. NA H removed her gloves and put on new gloves without performing hand hygiene. NA H rolled Resident #26 to the left side, removed the soiled brief, and placed 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.