Reunion Plaza Senior Care and Rehabilitation Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 7 of 18 residents dependent on staff reviewed for ADLs. (Resident #2, Resident #4, Resident #47, Resident #77, Resident #78, Resident #90, and Resident #104) 1.The facility failed to ensure Resident #2, Resident #4, Resident #77, Resident #78, Resident #90, and Resident #104 received scheduled baths in February of 2026. 2.The facility failed to ensure Resident #4, and Resident #47 were groomed and shaved. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem. The findings included: 1. Record review of an undated face sheet revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE] with diagnoses including diabetes, lack of coordination, and age-related physical disability. Record review of a quarterly MDS assessment dated [DATE] indicated…

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 refrain from utilizing the DON as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents for reviewed for nursing services. 1. The DON worked as a charge nurse or CNA 6 times in January 2026 2. The DON worked as a charge nurse or CNA 4 times in February 2026 This failure could place residents at risk by leaving nursing staff without supervisory coverage and leaving essential DON functions undone. Findings included: During observation and interview on 02/23/2026 at 10:00 a.m., the DON was changing linen on a bed in a resident room and stated she had to work the floor several nights as a charge nurse, be a CNA on the floor when the facility was short staffed. The DON stated she knew she was not supposed to work the floor in a building of more than 60 average residents. The DON stated she would take the citation because she was not leaving the residents with no care. The DON stated she was the monitor for the weight system, the skin system, the antibiotic stewardship…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1 of 7 resident's reviewed for pharmacy services. (Resident #1) The facility failed to administer Resident #1's physician ordered Debrox ear drops from 02/24/2026 to 02/26/2026. This failure could place residents at risk for medication errors and adverse effects from medication.The findings included: 1. Record review of face sheet, dated 02/25/2026, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis chronic obstructive pulmonary disease (chronic, progressive lung disease that makes it hard to breathe). Record review of the quarterly MDS assessment, dated 02/24/2026, reflected Resident #1 had clear speech, was understood, and was able to understand others. Resident #1 had a BIMS score of 12, 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 each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 7 of 19 residents (Resident #2, Resident #4, Resident #9, Resident #21, Resident #33, Resident #61, Resident #81) and 7 anonymous residents reviewed palatable food. 1. The facility failed to ensure residents received food that was palatable. 2. The facility failed to ensure residents received food with an appetizing appearance, texture, and appropriate temperature.These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.Record review of a Resident Council Meeting Form dated 09/30/25 indicated, .Food sometimes served cold on the halls.1. Record review of an undated face sheet revealed Resident #2 was an [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses including mild protein-calorie malnutrition (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote resident self-determination through support of family choice for 1 of 19 residents reviewed for resident rights. (Resident #78)The facility failed to place Resident #78's shoes on his feet daily as requested by family.The facility failed to get Resident #78 up out of bed daily as requested by family. These failures could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life.Record review of an undated face sheet revealed Resident #78 was [AGE] years old and admitted to the facility on [DATE] with diagnoses which including quadriplegia (paralysis affecting all four limbs and the torso, typically caused by cervical spinal cord injury), seizures, and high blood pressure.Record review of a quarterly MDS assessment dated [DATE] indicated Resident #78 was sometimes understood and sometimes understood others. The MDS indicated Resident #78 was unable to complete the BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide the resident access personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically, or, if not, in a readable hard copy from such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) and allow the resident to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the facility for 1 of 7 residents (Resident #105) reviewed for access of records. The facility failed to provide Resident #105's legal representative copies of medical records after a request was submitted to the facility on [DATE]. This failure could place residents at risk of violation of their rights by not receiving copies of their medical…

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 assess each resident quarterly (every 3 months) using the MDS form specified by the state and approved by CMS for 1 of 19 residents (Resident #20) reviewed for assessments. The facility failed to ensure Residents #20's quarterly MDS assessment was completed within 3 months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.The findings included: Record review of the face sheet, dated 02/25/2026, reflected Resident #20 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of osteomyelitis (bone infection) and dementia (decrease in memory and thinking ability that interferes with daily living). Record review of Resident #20's quarterly MDS assessment, dated 10/25/2026, reflected it was completed within 14 days of the ARD date. Record review of Resident #20's quarterly MDS assessment, dated 01/22/2026, reflected it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a Baseline Care Plan that included the instructions for resident care needed to provide effective and person-centered care for 3 of 12 residents reviewed for new admissions. (Resident #100, Resident #101, and Resident #103).The facility failed to develop a Baseline Care Plan for Resident #100's urinary catheter (tube inserted into the bladder to drain urine) within 48 hours of admission.The facility failed to develop a Baseline Care Plan for Resident #101 and Resident #103 within 48 hours of admission.This failure could place residents at risk of not receiving care and services to meet their needs.Findings included:1. Record review of Resident #100's face sheet dated [DATE] indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breath), cerebral infarction…

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 treatment and care in accordance with professional standards of practice for 1 of 13 (Resident #91) residents reviewed for quality of care. The facility failed to ensure a neurology referral was implemented for Resident #91, when it was ordered on 12/10/2025. These failures could place residents at an increased risk for a decreased quality of care, neglect, and decreased self-esteem.The finding included: Record review of the face sheet, dated 02/25/2026, reflected Resident #91 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of seizures (sudden, uncontrolled, and temporary burst of abnormal electrical activity in the brain, causing disturbances in awareness, behavior, sensation, or muscle function) and chronic migraine with aura, intractable (severe, recurrent headache preceded or accompanied by temporary neurological symptoms lasting over 72 hours). Record review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #90) of 12 residents reviewed for incontinent care. The facility failed to provide timely incontinent care for Resident #90 using appropriate techniques. This failure could place residents at risk for urinary tract infections, pain, and skin breakdown.Findings include: Record review of an undated face sheet revealed Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses of heart failure, obesity, and hypothyroidism (abnormally low activity of the thyroid gland). Record review of an annual MDS assessment dated [DATE] revealed Resident #90 had a BIMS of 14 indicating no cognitive impairment. She required dependent assistance with ADLs. Resident #90 was incontinent of bowel and bladder. Record review of the January and February 2026 ADL sheet printed 02/25/2026 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #31) reviewed for enteral tube management. The facility failed to ensure LVN O did not push Resident #31's medications by gastrostomy tube during medication administration on 02/24/2026. This failure could place residents with gastrostomy tube at risk for complications from medication administration such as stomach cramping or damage to the tube lining.The findings included: Record review of the face sheet, dated 02/25/2026, reflected Resident #31 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of gastrointestinal hemorrhage (bleeding in the stomach or intestinal tract), dysphagia (difficulty swallowing), and gastrostomy status (surgically created opening in the stomach wall). Record review of the quarterly MDS assessment, dated…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 7 errors out of 32 opportunities, resulting in a 21.88 percent medication error rate for 2 of 7 residents reviewed for medication error. (Resident's #20, #34) The facility did not ensure the following:1. Resident #20's Vitamin D3, magnesium oxide, multivitamin with minerals, B-12 methyl, and Vitamin C were administered on 02/24/2026.2. Resident #34's esomeprazole magnesium (for indigestion) and Bisacodyl suppository 10 mg was administered on 02/25/2026. These failures could place residents at risk for adverse reactions or ineffective dosage related to inaccurate drug administration. The findings included: 1. During an observation on 02/24/2026 beginning at 8:07 a.m., LVN O prepared Resident #20's medication for administration. LVN O prepared four pills, crushed them, mixed them with a small amount of apple sauce and administered them to Resident #20. LVN O did not include Resident #20's scheduled vitamin C, B-12 methyl, magnesium oxide,…

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 all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 8 resident reviewed for physical environment (Resident #4). Resident #4's electrical bed remote had a short and would only let the head up. The remote would not let the head down or control the foot of the bed or the bed height. This deficient practice could result in decreased comfort, pain, the resident developing skin issues or deterioration of current wounds. Findings included: Record review of an undated face sheet revealed Resident #4 was a [AGE] year-old male admitted on [DATE] with diagnoses of CVA (cerebral vascular accident [stroke], hemiplegia to right side (paralysis to single side of the body), and vascular ulcers (slow-healing, painful, and often recurring open sores, typically forming around the ankles due to chronic vein disease, such as poor circulation or faulty valves). Record review of a quarterly MDS assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 6 residents reviewed for respiratory care. (Resident #1 and Resident #2)1. The facility failed to ensure Resident #1's oxygen concentrator (takes air from the surroundings, extracts oxygen and filters it into purified oxygen for resident to breathe) air intake area (mouth of the oxygen concentrator bringing in the air that will be processed) was not covered in gray fuzzy dust and hair-like particles.2. The facility failed to ensure Resident #1 received the physician's ordered amount of oxygen of 2 LPM by nasal cannula.3. The facility failed to ensure Resident #2's oral suction catheter was stored properly.These failures could place residents at risk of respiratory complications or respiratory infection. Findings included:1. Record review of Resident #1's face sheet dated 7/15/25 indicated she was [AGE] years old and admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to establish and maintain an infection 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 9 residents (Residents #2 and Resident #3) reviewed for infection control practices.1. The facility failed to ensure CNA A and CNA B did not contaminate Resident #2's clothing, draw pad, bedding, pillows, and feeding tube pole after performing incontinent care.2. The facility failed to ensure CNA A and CNA B donned (put on) a gown while performing incontinent care on Resident #2, who was on Enhanced Barrier Precautions (EBP).3. The facility failed to ensure LVN C donned a gown while disconnecting Resident #3's feeding tube, assessing feeding tube placement, and attempting to flush the feeding tube, and the resident was on Enhanced Barrier Precautions.These failures could place residents at risk for cross…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 3 of 5 residents (Resident #33, Resident #65, and Resident #80) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #33 had the correct diagnoses on entered orders for the use of diabetes mellitus medications. 2. The facility failed to ensure Resident #65 had documented the correct diagnoses on entered orders for use of Acetaminophen 300 mg-codeine 30 mg (is used to help relieve mild to moderate pain), Lisinopril (is a medicine to treat high blood pressure (hypertension) and heart failure), Metoprolol (is used to treat angina (chest pain) and hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 18 residents (Residents #80) reviewed for pharmacy The facility failed to ensure Resident #80 Amlodipine, Carvedilol, Hydralazine, and Losartan were not administered when her blood pressure and/or pulse were outside of the ordered parameters on 11/03/24, 11/06/24, and 11/10/24. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #80's face sheet dated 12/02/24, indicated a 59-years-old female who admitted on [DATE] and readmitted on [DATE]. Resident #80 had diagnoses including cerebral infarction (is a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), pain, hyperlipidemia (is a condition where there are abnormally high levels of lipids or fats in the blood), and hypertension (is a chronic condition…

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 the menus met the nutritional needs of residents and were followed for 2 of 2 meals (the lunch meals on 12/2/24 and 12/3/24) reviewed for nutritional adequacy. The facility did not serve the posted lunch menu of breadstick and iced cinnamon raisin bars on 12/02/24. Cook Q did not follow the recipe for cheesy rice by using sliced cheese instead of shredded cheese per the recipe on 12/03/24. The facility did not follow the soup recipe on 12/03/24 by serving canned mushroom soup instead of homemade soup. The facility failed to use the appropriate size serving scooper for the pureed chicken, tomatoes and okra and potatoes and ground chicken for the lunch meal service on 12/03/24. The facility failed to ensure [NAME] Q scooped full serving sizes during the lunch meal on 12/03/24. These failures could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of a…

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

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 7 of 86 residents (Resident #77, Resident #52, Resident #83, Resident #50, Resident #74, Resident #62, and Resident #40), 1 of 1 family member (Resident #63), and 1 of 1 meal (Lunch meal) reviewed for food and nutrition services. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #77, Resident #52, Resident #83, Resident #50, Resident #74, Resident #62, and Resident #40, and a family member of Resident #63, who complained the food was served cold, was bland, over, or undercooked and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 12/02/24 at 9:35 a.m., Resident #52 said the food was not that good. She said the breakfast was cold and sometimes dinner was cold too. She said sometimes the alternative choice 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.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen refrigerator was labeled and dated on 12/02/24. 2. The facility failed to ensure cookware stored in the pantry and main kitchen area did not have carbon build up on 12/02/24. 3. The facility failed to ensure containers of cornmeal and sugar were properly sealed on 12/02/24. 4. The facility failed to ensure cornmeal was not spilled on the dry pantry floor on 12/02/24. 5. The facility failed to ensure 3 white bins, storing metal lids, did not have food particles in them on 12/02/24. 6. The facility failed to ensure the food steamer did not have a brown film and food particles at the bottom on 12/03/24. 7. The facility failed to ensure the pureed chicken, ground chicken, canned soup, pureed tomatoes and okra, 2nd batch of mashed potatoes and 2nd pan of chicken breast were temped before serving 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 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 2 of 3 residents (Resident #63 and Resident #65) reviewed for infection control. The facility failed to ensure, on 12/04/24, CNA E and CNA L, changed their gloves and performed hand hygiene appropriately while providing catheter care to Resident #65. The facility failed to ensure, on 12/04/24, CNA F, changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #63. These failures could place residents at risk of exposure to cross-contamination and infections. Findings included: Record review of Resident #65's face sheet dated 12/02/24 indicated a 76-years-old female admitted to the facility on [DATE]. Resident #65 had diagnoses including metabolic encephalopathy (is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 resident (Resident #57) reviewed for resident rights. The facility failed to ensure CNA S treated Resident #57 with respect and dignity when CNA S left Resident #57 exposed to the hallway after leaving her room. These failures could place residents at risk for diminished quality of life, loss of dignity, and self-worth. Findings included: Record review of Resident #57's face sheet, dated 12/05/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities), and anxiety disorder (a mental health condition that causes uncontrollable and excessive feelings of fear or anxiety that can significantly impair a person's daily life). 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 observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or others for 1 of 6 residents (Resident #35) reviewed for reasonable accommodations of needs. The facility failed to ensure Resident #35 had a call light within reach. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs. Findings include: Record review of Resident #35's face sheet dated 12/05/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included: legal blindness, glaucoma secondary to other eye disorders, left eye, severe stage (a group of eye conditions that can cause blindness) and fracture of unspecified part of neck of right femur. Record review of Resident #35's MDS, dated [DATE], 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.

Based on interview, and record review the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey including any plans of correction without identifying information about complainants or residents for 2 of 2 survey results binders reviewed. The facility failed to ensure the most recent abbreviated standard survey results, exit date 08/15/24, was posted in the survey results book. This failure could place residents at risk of not being aware of past and current violation findings from state surveys and investigations conducted in the facility. Findings included: During a record review on 12/03/24 at 11:23 AM, this surveyor reviewed the survey/inspection results book in the lobby of the facility. The most recent state visit result in both binders was dated 12/01/23. During a record review on 12/04/24 at 08:28 AM, this surveyor reviewed the survey/inspection results book in the lobby of the facility. The most recent state visit result in both binders was dated 12/01/23. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 4 residents (Resident #76) reviewed for PASRR. The facility failed to refer Resident #76 for PASRR review following new mental illness diagnosis of major depression disorder (mood disorder that causes persistent sadness and loss of interest) on 05/13/24. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #76's face sheet dated 12/03/24, indicated a 64-years-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #76 had diagnoses including cerebral infarction (is a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), brief psychotic disorder (severe mental illnesses 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 observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 2 (Resident #63 and Resident #80) of 18 residents reviewed for care plans. The facility failed to ensure Resident #63, per her care plan intervention, had a pillow placed in her wheelchair due to leaning on 12/02/24 and 12/03/24. The facility failed to document/monitor Resident #80's oral intake per her care plan intervention due to her altered nutritional status in November 2024. These failures could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life. Findings included: Record review of Resident #63's face sheet dated 12/02/24, indicated an 84-years-old female who admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 5 residents (Resident #80) reviewed for ADL (activities of daily living) care. The facility failed to ensure Resident #80 was gotten out of bed in November 2024. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, decrease socialization and skin breakdown. Findings included: Record review of Resident #80's face sheet dated 12/02/24, indicated a 59-years-old female who admitted on [DATE] and readmitted on [DATE]. Resident #80 had diagnoses including cerebral infarction (is a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), hemiplegia (is a condition that causes paralysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 5 Residents (Resident #65) whose record were reviewed for skin integrity. The facility failed to ensure Resident #65's pressure-relieving mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers. Findings included: Record review of Resident #65 face sheet dated 12/02/24 indicated a 76-years-old female admitted to the facility on [DATE]. Resident #65 had diagnoses including metabolic encephalopathy (is a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), urinary tract infection (is a common bacterial infection that occurs 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 that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 2 of 5 residents (Resident #65 and Resident #63) reviewed for quality of care. The facility failed to ensure CNA E and CNA L provided peri care/catheter care per the facility's policy for Resident #65 on 12/04/24. The facility failed to ensure, on 12/04/24, Resident #63 did not have feces on her thigh and brown stained creases on the legs portion of her brief. These failures could place residents at risk for urinary tract infections. Findings included: Record review of Resident #65 face sheet dated 12/02/24 indicated a 76-years-old female admitted to the facility on [DATE]. Resident #65 had diagnoses including metabolic encephalopathy (is a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), urinary tract…

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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #81) reviewed for nutrition. 1. The facility failed to follow the dietician's recommended tube feeding for Resident #81 to receive Glucerna 1.5 at 60 ml/hr beginning 9/14/24. 2. The facility failed to follow the dietician's recommendation of weekly weights beginning 11/15/24 for Resident #81. 3. The facility did not follow up on Resident #81's 9.12% weight loss in 3 months. These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life. Findings included: Record review of Resident #81's face sheet dated 12/3/24 indicated Resident #81 was a [AGE] year-old male that admitted [DATE] 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 interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 18 residents (Residents #80) reviewed for pharmacy services. The facility failed to ensure Resident #80 had accurate and new readings for each administration of Hydralazine (is used to treat high blood pressure) on 11/01/24, 11/02/24, 11/06/24, 11/07/24, 11/11/24, 11/15/24, and 11/16/24. This failure could place residents at risk for inaccurate drug administration. Findings included: Record review of Resident #80's face sheet dated 12/02/24, indicated a 59-years-old female who admitted on [DATE] and readmitted on [DATE]. Resident #80 had diagnoses including cerebral infarction (is a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death) and hypertension (is a chronic condition where the pressure of blood in your arteries is consistently too high). 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 ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring and diagnosis) for 2 (Resident # 65 and Resident #80) of 5 residents whose medications were reviewed. The facility failed to ensure Resident #65 had an appropriate diagnosis on entered order for her prescribed Escitalopram (is commonly used to treat depression and anxiety). The facility failed to ensure Resident #80 had behavior monitoring for her prescribed Venlafaxine (is used to treat major depressive disorder, anxiety, and panic disorder), Divalproex (is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder and to prevent migraine headaches), and Mirtazapine (is an atypical antidepressant and is used primarily for the treatment of a major depressive disorder). Finding included: Record review of Resident #65's face sheet dated 12/02/24 indicated a 76-years-old female admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 18 residents (Resident #77) reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #77's preference for boiled eggs at breakfast on 12/03/24, 12/04/24, and 12/05/24. The facility failed to obtain Resident #77's meals choice for each meal. These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings included: Record review of Resident #77's face sheet dated 12/02/24 indicated a 61-years-old male admitted to the facility on [DATE]. Resident #77 had diagnoses including cerebral infarction (stroke), major depressive disorder (is a serious mental health condition that affects how a person feels, thinks, and acts), and hemiplegia (is a condition that causes paralysis or weakness in one side of the body) 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 each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 4 of 12 residents (Residents #18, #6, #8, and #10), reviewed for care plans. 1.The facility failed to revise and update Resident #18's care plan following physically aggressive behaviors against another resident. No interventions for aggressive behavior were listed on the behavior care plan. 2.The facility failed to revise and update Resident #6's care plan with interventions following a fall with major injury. The care plan did not include Resident #6's hip fracture or interventions for the care of the hip fracture. 3.The facility failed to revise and update Resident #8 and add interventions of a scoop mattress, move bedroom closer to nurses' station, and applying a fall mat beside bed after fall on 04/10/2024. 4. The facility failed to include added interventions of a fall mat and pommel cushion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to 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 12 residents reviewed for resident rights. (Resident #32) The facility failed to promote self-determination for Resident #32 by not allowing her to make healthcare decisions for herself when on 06/16/2024, LVN M, who was an agency nurse, refused to call an ambulance for Resident #32 because she felt Resident #32 was medically stable at the facility. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings included: Record review of an undated face sheet reflected Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of PVD (peripheral vascular disease- poor circulation), sepsis (severe infection), and diabetes mellitus type II. She was discharged [DATE]. Record review of Resident #32's 5-day…

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 were free from abuse for 2 of 27 residents (Resident #1 and Resident #3) reviewed for resident abuse. 1.The facility failed to ensure Resident #1 was free from abuse when on 11/02/2023 CNA H shook Resident #1's wheelchair when pushing into the bathroom for incontinent care. 2.The facility failed to ensure Resident #3 was free from abuse when on 6/20/24 CNA J forcefully pushed Resident #3's wheelchair with her in it, from the doorway of her room to the doorway of another room across the hallway (approximately 13 foot). These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress. The findings included: 1.Record review of Resident #1's face sheet, dated 8/13/24, revealed she was [AGE] years old and initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses of dementia (progressive loss of intellectual functioning, especially with impaired…

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 an effective discharge planning process for 1 of 15 residents (Resident #32) reviewed for care plans. The facility failed to prepare Resident #32 to effectively transition to post-discharge care and the reduction of factors leading to preventable readmissions. These negative findings could cause a resident to have an unsafe living environment upon discharge. Findings included: Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of PVD (peripheral vascular disease- poor circulation), sepsis (severe infection), and diabetes mellitus type II. Record review of Resident #32's 5-day MDS assessment dated [DATE] indicated she had a BIMS of 15 and required substantial to maximum assistance for toileting, transfer and hygiene. The MDS indicated Resident #32 received dialysis during her stay. No behaviors were noted on the MDS. The MDS indicated…

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 residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #14) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #14 had supervision that prevented him from going outside and falling causing a hematoma and abrasion to his head. This failure could result in residents experiencing accident, injuries, and diminished quality of life. Findings included: 1. Record review of an undated face sheet reflected Resident #14 was a [AGE] year-old male that admitted to the facility on [DATE] with the diagnosis of dementia, atrial fibrillation (irregular heartbeat), and diabetes mellitus type II and discharged [DATE]. Record review of Resident #14's admission MDS dated [DATE] reflected he had a BIMS of 01 which indicated severe cognitive impairment. The MDS also indicated Resident #14 had some physically aggressive behavior and he required partial to moderate assistance with ADLs.…

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 of any significant medication errors for 1 of 12 residents reviewed for medications. (Resident #32) The facility failed to ensure Resident #32's IV antibiotic (meropenem) was initiated per MD orders to begin on 06/07/2024. These failures could cause prolonged illness and increased recovery time for residents. Findings included: Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of PVD (peripheral vascular disease- poor circulation), sepsis (severe infection), and diabetes mellitus type II. Record review of Resident #32's 5-day MDS 06/12/2024 assessment indicated she had a BIMS of 15 and required substantial to maximum assistance for toileting, transfer and hygiene. The MDS indicated Resident #32 received dialysis during her stay. No behaviors were noted on the MDS. Record review of Resident #32's EHR revealed no care plans for IV…

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 grooming and personal hygiene were provided for 2 of 6 (Resident #2 and Resident #3) residents reviewed for ADLs. The facility did not provide scheduled showers for Resident #2 and Resident #3. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 12/01/23 indicated Resident #2 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including diabetes, weakness, hypertension (elevated blood pressure), and acute kidney failure (a condition where the kidneys suddenly cannot filter wastes from the blood). Record review of the comprehensive MDS dated [DATE] indicated Resident #2 understood others and usually was understood by others. The MDS indicated Resident #2 had a BIMS of 11 and was…

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

Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 2 of 4 (600 Hall Nurse/Medication and the Treatment Cart) medication carts and 1 of 2 (LVN G) nurses observed for medication storage. The facility did not ensure the medication carts were secured and unable to be accessed by unauthorized personnel. The facility failed to ensure medications were not left at the nurse's station unattended. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used passed their effective or expiration date, and a drug diversion. Findings include: 1. During an observation on 11/29/23 at 2:13 p.m. a Nurse/Medication cart on the 600 hall was unattended and unlocked. The MDS nurse, an LVN, and 2 other people walked by the unlocked cart and did not lock it while the surveyor was standing at the nurse's station. During an observation on 11/29/23 at 2:15 p.m. LVN G walked up and locked the unattended and unlocked medication cart. 2. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 7 residents reviewed for resident rights. (Resident #1) The facility did not ensure the window blinds were closed during incontinent care exposing Resident #1. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of the face sheet dated 12/02/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, chronic pain, and cerebral infarction (stroke). Record review of the Quarterly MDS dated [DATE] indicated Resident #1 usually understood other and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #1 was dependent for toileting, personal hygiene, and bed…

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 3 staff (CNA A) viewed for infection control. The facility failed to ensure CNA A changed gloves and perform hand hygiene while providing incontinent care. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. During an observation on 11/30/23 at 1:47 p.m. CNA A was performing incontinent care on Resident #1. CNA rolled up a dirty draw sheet, did not change gloves, then grabbed clean rag and wiped Resident #1's side off. CNA A placed a rag back in soapy water, did not change gloves, picked the call light up out of the floor, pulled the privacy curtain more closed, then exited room with the gloves on. CNA A entered the room without gloves on, did not perform hand hygiene,…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the plastic zipper bag labeled cocoa powder was securely closed. The facility failed to ensure the plastic trash-like bag labeled salt was securely closed. The facility failed to ensure there was not an uncovered unlabeled small cup of white granular substance left on the dry storage shelf. The facility failed to ensure the plastic trash-like bag labeled light brown cane sugar was securely closed. The facility failed to ensure the plastic bag labeled cheese was securely closed in the cooler. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour observations in the kitchen on 10/30/23 beginning at 9:05 AM, there was a plastic zipper bag labeled cocoa powder…

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 promotes maintenance or enhancement of his or her quality of life for 2 of 3 residents (Resident #72, and Resident #201) reviewed for resident rights. The facility failed to ensure LVN SS treated Resident #72 with respect and dignity. The facility failed to ensure CNA HH treated Resident #72 with respect and dignity. The facility failed to cover the foley catheter urine drainage bag with a privacy bag for Resident #201 while she was out of her room in public view. These failures could place residents at risk for diminished quality of life, loss of dignity, and self-worth. Findings included: 1. Record review of Resident #72's face sheet, dated 11/01/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects nerve cells in the brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care and provide the resident and their representative with a summary of the baseline care plan that included goals of the resident, summary of medications and dietary instructions, and services and treatments within 48 hours of admission for 4 of 10 residents reviewed for baseline care plans. (Resident #94, Resident #352, Resident #358, and Resident #361) 1.The facility failed to develop a baseline care plan with initial goals and the minimum healthcare information necessary to provide person-centered care within 48 hours of admission for Resident #94, Resident #352, Resident #358, and Resident #361. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #94's face sheet dated 10/31/23 indicated Resident #94 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 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 dressing, bathing, and bed mobility were provided for 4 of 24 residents reviewed for ADLs (Resident #22, Resident #29, Resident #45, and Resident #79.) The facility failed to provide Resident #29 with timely incontinence care. The facility failed to assist Resident #22 with daily dressing. The facility did not provide scheduled showers for Resident #22, Resident #45, and Resident #79. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings included: 1. Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including Dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block…

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

Based on observation, interview and record review, the facility failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents for 10 shifts in the last 90 days. The census was 96. The DON worked as a charge nurse or CNA 3 times in August 2023 The DON worked as a charge nurse or CNA 3 times in September 2023. The DON worked as a charge nurse or CNA 4 times in October 2023. This failure could place residents at risk by leaving nursing staff without supervisory coverage and leaving essential DON functions undone. Findings included: During observation and interview on 10/30/2023 at 10:00 a.m., the DON was changing linen on a bed in a resident room and stated she has had to work the floor several nights as a charge nurse and has had to be a CNA on the floor when the facility was short staffed. The DON stated she knew she was not supposed to work the floor in a building of more than 60 average residents. The DON stated she would take the citation because she was not leaving the residents with no care and there was no one…

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 administering of all drugs and biologicals, to meet the needs of 1 of 24 residents reviewed for pharmacy services. (Residents #83) The facility failed to provide Resident #83 with dronabinol 5mg and megace 40mg for multiple days in September and October 2023 due to medications not being available. This failure could place residents at risk for inaccurate drug administration and cause Resident #83 increased pain and weight loss. Findings included: 1. Record review of Resident 83's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), compression fracture of lumbar spine (small breaks in the vertebrae of the lower spinal column), and hypertension. Record review of Resident # 83's quarterly MDS, dated [DATE],…

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, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 5 residents (Resident #5, Resident #6) reviewed for unnecessary psychotropic medications. The facility failed to limit Resident #5's Lorazepam (anti-anxiety) prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use. The facility failed to have an appropriate diagnosis or indication of use for Resident #5's Lorazepam. The facility failed to document Resident #5's behaviors to justify administration of Lorazepam and effectiveness of administration. The facility failed to have an appropriate diagnosis or indication of use for Resident #6's Seroquel (Quetiapine Fumarate; antipsychotic). The facility failed to have an appropriate diagnosis or indication…

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 it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 18.92%, based on 7 errors out of 37 opportunities, which involved 4 of 7 residents (Resident #18, Resident #50, Resident #25, and Resident #39) reviewed for medication administration. The facility failed to administer Resident #18's loratadine (used to temporarily relieve the symptoms of hay fever [allergy to pollen, dust, or other substances in the air] and other allergies.) as ordered on 10/31/23. The facility failed to administer Resident #18's fluticasone propionate (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing) as ordered on 10/31/23 The facility failed to administer Resident #50's potassium chloride extended release (a mineral supplement used to treat or prevent low amounts of potassium in the blood) as ordered on 10/31/23. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 22 residents reviewed for infection control. (Resident #19, Resident #64, Resident #27, Resident #94, Resident #352, and Resident #358) The facility failed to clean Resident #19's room after she had a nosebleed. The facility failed to ensure Resident's # 64's wheelchair was free of soiled adult briefs. The facility failed to ensure WCN NN practiced infection control measures by changing gloves after touching items during a wound dressing change for Resident #27. The facility failed to ensure PICC line (catheter inserted into a large vein that carries blood to the heart and it is used to deliver long-term medications into the blood) dressings were changed weekly per the facility's policy for Resident #94, Resident #352, and Resident #358.…

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 the residents had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for three (Resident #26, #35, #83) of five residents reviewed for care planning. The facility failed to ensure the IDT, Resident #26, Resident #35 and Resident #83, and the POA/RP of Resident #26, Resident #35, and Resident #83 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings included: 1. Record review of Resident 26's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her 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 residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 22 residents (Resident #3, Resident #7, and Resident #27) reviewed for reasonable accommodations. The facility failed to ensure Resident #3, Resident #7 and Resident#27 call lights were within reach. This failure could place residents at risk for unmet needs. Findings included: 1. Record review of Resident #3's face sheet dated 11/02/23 indicated Resident #3 was 91-years-old male and admitted on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning), malignant neoplasm of prostate (is a disease in which malignant (cancer) cells form in the tissues of the prostate) and muscle weakness. Record review of Resident #3's significant change in status MDS assessment dated [DATE] indicated Resident #3 was usually understood 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 interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 22 residents (Resident # 5, Resident #29, and Resident #361) reviewed for MDS assessment accuracy. The facility failed to code Resident #5's use of oxygen on her MDS. The facility failed to code Resident #29's use of oxygen and being on hospice services. The facility failed to accurately reflect Resident #361 had a pressure ulcer on his admission MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #5's face sheet dated 10/30/23 indicated Resident #5 was a [AGE] year-old female and admitted on [DATE] with diagnosis including cerebral ischemia (is the lack of blood supply to a region of the brain, resulting in a low supply of oxygen and nutrients) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). 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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 1 resident's (Resident #75) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #75. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner. Findings included: Record review of Resident #75's face sheet, dated 11/02/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Record review of Resident #75's quarterly MDS assessment, dated 08/10/23, indicated she rarely/never…

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 to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 2 residents reviewed for care plans. (Resident# 29) The facility failed to implement the care plan intervention to report to Resident #29's provider, of his blood glucose levels (is a test that mainly screens for diabetes by measuring the level of glucose (sugar) in your blood) that were less than 100 per the physician orders. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: Record review of Resident #29's face sheet dated 10/30/23 indicated Resident #29 was 91-years-old male and admitted on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete a discharge summary that included but is not limited to, (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. and resident's follow up care and any post-discharge medical and non-medical services for 1. (Residents #202) of four residents reviewed for discharge planning. 1. The facility failed to complete a recapitulation of Resident #202's stay. 2. The facility failed to ensure Resident #202 had a physician prescribed wheelchair, bedside commode, and shower transfer bench when he was discharged home alone. This failure could place residents at risk of decreased socialization, depression, impaired skin integrity and increased fall risk. Findings included: 1) Review of the face sheet for Resident #202 reflected the resident was a 68-year- old- male that admitted on [DATE] with the diagnoses of right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide resident with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 1 of 3 residents reviewed for limited range of motion (Resident #75). The facility failed to provide restorative therapy for Resident #75's contracture. The facility failed to provide physical therapy for Resident #75's contracture. The facility failed to provide occupational therapy for Resident #75's contracture. These failures could place resident who had contractures at risk of not attaining or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: Record review of Resident #75's face sheet, dated 11/02/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and bipolar disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 34 residents (Resident #76 and Resident # 18) reviewed for adequate supervision. The facility failed to store, supervise, and distribute Resident #76's smoking materials. The facility failed to ensure CNA CC and CNA DD safely transferred Resident #18 The facility failed to ensure CNA CC and CNA DD locked the shower chair wheels before transferring Resident #18. The facility failed to ensure CNA CC and CNA DD used a gait belt to transfer Resident #18. This failure could place residents at risk for injury, harm, and impairment or death. Findings included: 1. Record review of Resident #76's admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it),…

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 7 residents (Resident #27) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)). The facility failed to ensure Resident #27's indwelling catheter (drains urine from your bladder into a bag outside your body) remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag) and had a leg strap to anchor catheter to his leg. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #27's face sheet dated 10/30/23 indicated Resident #27 was a [AGE] year-old male and admitted on [DATE] and 04/06/23 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 ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 3 resident (Resident #3, Resident #6) reviewed for hydration. The facility failed to ensure Resident #3 and Resident #6 hydration was within reach. This failure could place residents at risk for dehydration (occurs when your body loses more fluid than you take in), electrolyte imbalance (occurs when certain mineral levels in your blood get too high or too low), and infections. Findings included: 1. Record review of Resident #3's face sheet dated 11/02/23 indicated Resident #3 was 91-years-old male and admitted on [DATE] with diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning), malignant neoplasm of prostate (is a disease in which malignant (cancer) cells form in the tissues of the prostate) and muscle weakness. Record review of Resident #3's significant change in status 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 each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #29) reviewed for unnecessary medications in that: The facility failed to ensure Resident #29 had appropriate diagnoses for the use of Acetaminophen (is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds and fevers), Albuterol (is used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways)), Boost (a nutrient-packed high protein…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 4 residents reviewed for antibiotic use. (Resident #29) The facility failed to ensure Resident #29's urinalysis (is a test that examines the visual, chemical, and microscopic aspects of your urine) with a culture (checks urine for germs (microorganisms) that cause infections) was collected prior to antibiotics starting. The facility failed to ensure Resident #29 Cefdinir (is used to treat bacterial infections in many different parts of the body) has an appropriate diagnosis for indication of use. The facility failed to ensure Resident #29 was not treated with an antibiotic when lab work did not indicate a urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra). This…

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 effective pest control program to keep the facility free of pest for one (room [ROOM NUMBER]) of 6 rooms reviewed for pests. The facility failed to treat room [ROOM NUMBER] for roaches. These failures placed residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: During an observation on 10/31/23 at 9:30 a.m. surveyor spotted approximately 10-15 roaches near some boxes stored on the floor of room [ROOM NUMBER]. There were food crumbs on the floor, stacked boxes with personal belongings of the resident, and large roaches were visible when the boxes were disturbed. During an interview on 10/31/23 at 9:38 a.m. with the Maintenance Supervisor he stated the facility is contracted with a Pest Control company who comes out once a month to the facility to inspect and spray for pests. He stated currently the facility does not have a pest control…

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 communication with and access to services inside the facility as mandated by the PASRR program were coordinated for 1 (Resident #2) of the 3 residents reviewed for resident rights. The facility failed to communicate with and coordinate therapy services that as mandated by the PASRR program for Resident #2. This failure placed residents at risk for diminished quality of life, and loss of dignity and self-worth. Findings included: 1. Record review of a face sheet dated10/03/2023 revealed Resident #2 was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of cerebral palsy (caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), paranoid schizophrenia (stems from delusions-firmly held beliefs that persist despite evidence to the contrary-and hallucinations-seeing or hearing things that others do not), and muscle weakness.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to promote resident self-determination through support of family choice for 1 of 6 residents reviewed for resident rights. (Resident #1) The facility did not place Resident #1's tennis shoes on his feet daily per family requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never understood. The MDS indicated Resident #1 was totally dependent on staff for all ADLs including dressing. Record review of a care plan last revised on 05/31/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one out of one resident (Resident #2) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #2. These failures could place residents identified at a Level II for PASRR Evaluation at risk for their specialized services not being provided in a timely manner. Findings include: 1. Record review of a face sheet dated10/03/2023 revealed Resident #2 was a [AGE] year-old female that admitted to the facility on [DATE] with the diagnoses of cerebral palsy (caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles), paranoid schizophrenia (stems from delusions-firmly held beliefs that persist despite evidence to the contrary-and hallucinations-seeing or hearing things that others do not), 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 provide the necessary services to maintain personal hygiene for 1 of 6 residents reviewed for ADLs. (Resident #1) The facility failed to provide incontinent care to keep Resident #1 clean and dry. The facility failed to provide scheduled baths/showers for Resident #1. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being…

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 1 of 5 residents reviewed for range of motion. (Resident #1) The facility did not provide restorative therapy for Resident #1's contractures. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. Record review of physician's orders dated 10/04/23 did not indicate an order for restorative therapy for Resident #1. Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated…

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 respiratory care was provided consistent with professional standards of practice for 1 of 7 residents reviewed for respiratory care. (Resident #1) The facility failed to ensure Resident #1's suction tip catheter (suction equipment used for oral suctioning) was properly stored. These failures could place residents at risk of respiratory complications or respiratory infection. Findings included: Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. Record review of physician's orders dated 10/04/23 did not indicate an order for restorative therapy for Resident #1. Record review of the most recent MDS dated [DATE] indicated Resident #1 was rarely to never understood. The MDS indicated a BIMS was not conducted due to Resident #1 being rarely to never…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 7 residents reviewed for pharmacy services. (Resident #1) The facility failed administer all scheduled medications to Resident #1. This failure could place residents at risk for inaccurate drug administration and side effects from missed doses of medication. Findings included: Record review of a face sheet dated 10/03/23 revealed Resident #1 was [AGE] years old and was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), muscle spasms, and recurrent depressive disorders. Record review of physician's orders dated 10/04/23 indicated an order for Amlodipine (blood pressure medication) 5 milligram tablet, 1 tablet 1 time per day with a start date on 06/27/21. There was an order for Claritin (medication for allergy symptoms) 10 milligram tablet, 1 tablet 1 time…

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