Heritage Plaza Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review 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 3 of 13 residents (Resident #12, #22, and #196) reviewed for infection control practices. 1. The facility failed to ensure signage was located outside Resident #196's room to indicate he required transmission-based droplet precautions. 2. The facility failed to ensure CNA C used transmission-based droplet precautions when entering Resident #196's room. 3. The facility failed to ensure CNA L changed her gloves and perform hand hygiene during Resident #12's indwelling foley catheter care. 4. The facility failed to ensure LVN A and CNA B followed the Enhanced Barrier Precautions (EBP) (interventions to prevent spread of infection in high-risk residents) policy of wearing a gown during Resident #22's wound care 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 observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 13 residents (Resident #12) reviewed for resident rights. The facility failed to ensure Resident #12's catheter drainage bag was in a privacy bag. This failure could place residents at an increased risk of embarrassment and a diminished quality of life. The findings included: Record review of the face sheet, dated 04/23/25, reflected Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia with behaviors (memory loss) and chronic kidney disease (gradual loss of kidney function). Record review of the quarterly MDS assessment, dated 01/30/2025, reflected Resident #12 had clear speech and was sometimes understood by staff. The MDS reflected Resident #12 was rarely/never able to understand others. The MDS reflected…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 13 residents reviewed for activities. (Residents #2 and Resident #33) The facility failed to provide Residents #2 and Resident #33 with consistent, scheduled activities. 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: 1. Record review of the face sheet 04/22/25 indicated Resident #2 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, peripheral vascular disease (a condition where blood flow to the extremities, particularly the legs and arms, is restricted due to narrowing or blockage of blood vessels), and pain. Record Review of Physician's Orders for Resident #2 reviewed on 04/22/25 indicated an…

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

Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed for Activity Director. The facility failed to employ a certified activities director. This failure could place the residents at risk of not receiving a program of activities that meets their assessed activity needs. Findings included: Record review of a personnel file for the Activity Director revealed did not indicate an Activity Director Certification and the Activity Director had 2 years of experience in a social or recreational program. The personnel file indicated a hire date of 05/08/19. Record review of a letter dated 04/02/25 and addressed to the Activity Director indicated confirmation of enrollment in a course to begin in August 2025 that taught the standardized National Council of Certified Activity Profession curriculum. During an interview on 04/23/25 at 9:59 a.m., the Activity Director said she became the Activity Director on 01/06/25. She said before that she was a CNA on the floor and worked in…

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

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 and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 13 residents (Resident #196) reviewed for accidents and supervision. The facility failed to ensure CNA H performed a safe mechanical lift transfer for Resident #196. This failure could place residents at risk of injury. Findings include: Record review of Resident #196's face sheet dated 4/22/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #196 had diagnoses which included dementia (forgetfulness), heart failure, hypertension (high blood pressure), and anxiety (feeling of worry). Record review of the MDS assessment list, accessed 04/22/25, reflected Resident #196's admission MDS had not been completed yet. Record review of Resident #169's Care Plan dated 4/22/25 indicated he was at risk for falls, and 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 observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #12) reviewed for treatment and services related to indwelling catheters. 1. The facility failed to ensure CNA L changed her gloves and performed hand hygiene during Foley catheter care. 2. The facility failed to ensure Resident #12's indwelling Foley catheter had a catheter securement device to anchor the catheter to her leg. 3. The facility failed to ensure Resident #12's Foley catheter drainage bag was kept off the floor. These failures could place residents at risk for urinary tract infections, injuries, and a decreased quality of life. The findings included: Record review of the face sheet, dated 04/23/25, reflected Resident #12 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of unspecified dementia with behaviors (memory loss) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident (Resident #38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #38 had a history of trauma. This failure could put residents at an increased risk for psychological distress due to re-traumatization. The findings included: Record review of the face sheet, dated 04/22/25, reflected Resident #38 was a [AGE] year-old male who initially admitted to the facility on [DATE] with a diagnosis of unspecified dementia (memory loss). Record review of the admission referral packet, dated 11/08/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 17 residents (Resident #4) reviewed for resident rights. The facility failed to ensure Resident #4 had a dignified existence by allowing her to be covered in feces on 2/27/25. These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and loss of self-worth. Findings included: Record review of Resident #4's face sheet dated 3/03/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #4 had diagnoses which included diverticulitis (occurs when an infected pouch becomes filled with pus) of large intestine with perforation (rupture) and abscess (pocket of pus), hypertension (high blood pressure), and depression (persistent sadness that can interfere with daily life). Record review of Resident #4's MDS assessment…

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 each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 17 (Resident #1 and Resident #2) residents reviewed for call lights. The facility failed to ensure call lights were within reach while Resident #1 and Resident #2 were in bed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1. Record review of Resident #1's face sheet dated 03/03/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia, amputation at knee level of right lower leg, and impulse disorder (a group of behavioral conditions that make it hard to control reactions or actions). Record review of Resident #1's annual MDS assessment dated [DATE], indicated he had a BIMs score of 10, which indicated she had moderate…

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 the right to be free from abuse was provided for 1 of 18 reviewed for abuse. (Resident #3) The facility failed to ensure Resident #3 was free from abuse when CNA D told him, all you do is lie and that's why people don't want to deal with you. This failure could place residents at risk for abuse. Findings included: Record review of a face sheet dated 03/03/25 revealed Resident #3 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), and insomnia (a common sleep disorder characterized by difficulty falling or staying asleep, resulting in poor sleep quality and daytime fatigue). Record review of the MDS dated [DATE] revealed Resident #3 had a BIMS score of 7, indicating severe cognitive impairment. The MDS indicated Resident #3 required moderate to maximal assistance with most ADLs. Record review of a 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 residents who required colostomy, urostomy, or ileostomy services, received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #4) reviewed for ostomy care. The facility failed to provide Resident #4 with appropriate colostomy care resulting in her colostomy leaking and covering her in feces. This failure could place the resident at risk of skin irritation and breakdown from exposure to fecal matter. Findings included: Record review of Resident #4's face sheet dated 3/03/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #4 had diagnoses which included diverticulitis (occurs when an infected pouch becomes filled with pus) of large intestine with perforation (rupture) and abscess (pocket of pus), hypertension (high blood pressure), and depression (persistent sadness that…

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 comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1's refusal of care, refusal to be repositioned, and refusal to take medications. This failure could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: Record review of Resident #1's face sheet dated 11/01/24 revealed he was [AGE] years old and admitted to the facility on [DATE] and discharged on 10/23/24. Resident #1 had diagnoses of acute respiratory failure with hypoxia (lack of adequate oxygen in the body's tissues to sustain function), cardiomyopathy (disease of the heart muscle which makes it hard for the heart 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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 4 residents reviewed for resident rights. (Resident #1 and Resident #4) 1. The facility failed to treat Resident #1 with dignity and respect by denying his request to be repositioned in bed. 2. The facility failed to treat Resident #4 with dignity and respect when the previous Administrator told him he looked like a child molester on 03/25/24. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: 1. Record review of an undated face sheet indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), major…

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 were free from abuse for 2 of 14 residents (Resident #1 and Resident #2) reviewed for resident abuse. 1.The facility failed to ensure Resident # 1, was free from physical abuse when CNA A roughly placed his legs into the bed when he asked for assistance into bed. 2.The facility failed to ensure Resident #2 was free from abuse when CNA E verbally abused him on 4/09/24. These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings included: 1.Record review of an undated face sheet indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), major depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant…

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, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 14 residents (Resident #1) reviewed for abuse. The facility failed to report an allegation of physical abuse within 2 hours of the allegation being reported to the ADON on 04/09/2024. The ADM (abuse coordinator) reported the abuse to HHS on 04/17/2024 within 1 hours of being notified of the allegation of abuse by the ADON. These failures could place residents at risk of physical…

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 allow for private Resident Council meetings and without facility staff present for 5 of 5 Residents reviewed for resident rights. The facility failed to provide a private space for Resident Council meetings. The facility failed to inform members of the Resident Council they could have their meetings in private and staff could only attend if invited. This failure placed residents at risk of not having the right to voice their concerns without staff being present or overhearing their concerns and to conduct resident council meetings without interference. Findings include: During a confidential resident group interview on 3/5/2024 at 10:00 a.m., the residents in attendance stated that the Resident Council meetings were always held in the dining room. All residents in the confidential group interview were upset and unhappy that staff continuously interrupted the resident council meeting. All residents agreed they would feel more willing to express their views without a staff person being able to overhear the meeting. During…

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 pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 10 residents reviewed for quality of care. (Resident #144) The facility failed to manage Resident #144's pain by not administering his ordered pain medication. This failure placed residents at risk for increased pain, decline in mobility, functioning, inability to perform activities of daily living and decreased quality of life. Findings Include: Record review of a face sheet dated 03/01/24 revealed Resident #144 was [AGE] years old and was admitted on [DATE] with diagnoses including fracture of the right scapula (the scapula is a thick, flat bone lying on the thoracic wall), fracture of ribs right side, fracture of left tibia (the tibia is the shinbone, the larger of the two bones in the lower leg). Record review of the MDS assessment indicated Resident #144 did not have a MDS created yet as he was 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.

Based on observation, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments for 2 of 4 medication carts (100 hall cart and 300/400 hall cart) reviewed for pharmacy services. 1. The facility failed to lock 2 medication carts for hall 100 and 300/400 Halls split cart. 2. The facility failed to ensure LVN E removed expired eye drops from the nurse medication cart for 100-hall. These failures could place residents at risk of not having their medications available as prescribed, a drug diversion, and an adverse reaction to expired medications. Findings included: 1. During an observation on 3/5/2024 at 8:02 a.m., of the 100-hall nurse medication cart, when Multiple staff and residents were present in the hallway. There was no staff present at the medication cart. The ADM was nearby and approached the medication cart and locked it. LVN E said the cart was the 100-hall cart and the staff member for the cart was not in the facility. The unlocked medication cart had various medications for residents including multivitamins, eye drops,…

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 promote resident self-determination through support of resident choice for 2 of 12 residents reviewed for resident rights. (Resident #32, Resident #35) 1. The facility did not assist Resident #32 out of bed as often as she preferred. 2. The facility failed to shower Resident #35 instead of a bed bath per his request. These failures could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: 1. Record review of the face sheet dated 03/05/24 indicated Resident #32 was [AGE] years old and admitted on [DATE] with diagnoses including heart disease, diabetes, and anxiety disorder. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #32 was usually understood and usually understood others. The MDS indicated a BIMS score of 14 which indicated Resident #32 was cognitively intact. The MDS indicated Resident #32 was dependent on staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 12 residents reviewed for resident rights. (Resident #9) The facility failed to repair the wall behind the bed of Resident #9. This failure placed residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of a face sheet 03/05/24 indicated Resident #9 was [AGE] years old and was admitted on [DATE] with diagnoses including stroke, major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and diabetes. Record review of the MDS assessment dated [DATE] indicated Resident #9 was rarely/never understood and sometimes understood others. The MDS indicated a BIMS score of 0 indicating severe cognitive impairment. Record review of a care plan revised on 01/11/24 indicated Resident #9 had a history of 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 observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for 2 of 12 residents reviewed for quality of life (Resident #21 and Resident #35). 1.The facility failed to provide scheduled bath/showers for Resident #21. 2. The facility failed to provide scheduled bath/showers and shave Resident #35. These failures could place residents who required assistance from staff for ADLs at risk of poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Review of Resident #21's face sheet dated 3/04/2024 revealed that she was a [AGE] year-old and admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, and cerebral infarction. Record review of quarterly MDS assessment dated [DATE] revealed a BIMS with a score of 1, which indicated Resident #21 had severely…

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 an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 12 residents reviewed for quality of life. (Residents #32) 1.The facility failed to provide Residents #32 with consistent, scheduled activities . 2.The facility failed to provide Resident #32 with a calendar of scheduled activities. 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 a face sheet dated 03/05/24 indicated Resident #32 was [AGE] years old and admitted on [DATE] with diagnoses including heart disease, diabetes, and anxiety disorder. Record review of an admission MDS dated [DATE] indicated Resident #32 was usually understood and usually understood others. The MDS indicated a BIMS score of 14 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents (Resident #193) who were reviewed for quality of care. The facility failed to ensure Resident# 193 had an indwelling urinary catheter (tube inserted into the bladder to drain urine) securement/anchor device (used to secure an indwelling urinary catheter). This failure could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections. Findings included: Record review of Resident #193's face sheet dated 3/04/24 indicated Resident #193 was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #193 had diagnoses including cerebral infarction (lack of adequate blood supply to brain cells depriving them of oxygen causing parts of the brain to die), depression (persistent 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 maintain and ensure safe and sanitary storage of residents' food items for 1 of 6 resident personal refrigerators reviewed for food and nutrition services (Resident #11). The facility failed to ensure the refrigerator for Resident #11 did not contain expired and decomposing meat products. This failure could place resident at risk for food borne illnesses. Findings include: Record review of a face sheet dated 11/12/2019 indicated Resident #11 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Dementia (the loss of cognitive functioning), Anxiety (a feeling of fear, dread, and uneasiness), and Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should). Record review of an annual MDS assessment dated [DATE] indicated Resident #11 understood others and made herself understood. The MDS indicated Resident #11 had moderate cognitive impairment with a BIMS score of 09. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 11 residents (Resident # 1) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #1 had pressure ulcers, wounds, or skin problems on his admission MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #1's face sheet dated 2/12/24 revealed Resident #1 was admitted to the facility initially on 12/28/23 with diagnoses including malignant neoplasm of pancreas (pancreatic cancer-type of cancer often detected late, spreads rapidly, and poor prognosis), muscle weakness, anemia in chronic disease (blood does not have enough healthy red blood cells), abnormality of gait and mobility, lack of coordination, heart failure, and hypertension (high blood pressure). Record review of Resident #1's admission MDS dated [DATE] indicated Resident #1 was 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 interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure injury. The facility failed to adequately document Resident #1's wounds upon admission. The facility failed to measure Resident #1's wounds upon admission. The facility failed to obtain initial wound care orders for Resident #1's wounds. The facility failed to provide appropriate wound care for Resident #1 from admission [DATE] until seen by wound care specialist 1/3/24. These failures could place residents at risk for deterioration of wounds. Findings included: Record review of Resident #1's face sheet dated 2/12/24 revealed Resident #1 was admitted to the facility initially on 12/28/23 with diagnoses including malignant neoplasm of pancreas (pancreatic cancer-type of cancer often…

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 30-day notice to the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand before the resident was discharged for 1 of 1 (Resident #1) reviewed for Discharge Rights. The facility did not provide a written discharge notice to Resident #1 (who admitted on [DATE] and discharged on 01/16/23) or their representative prior to discharging the resident, not allowing the 30-day advance notice. The facility discharged Resident #1 to an acute hospital. This failure could place residents who are transferred or discharged from the facility, at risk for not receiving care and services to meet their needs upon discharge and the right to appeal. Findings included: Resident review of Resident #1's face sheet printed on 10/09/23 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] and discharged on 01/16/23 with diagnoses including acute…

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.