Trinity Rehabilitation & Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #16) reviewed for infection control. The facility failed to ensure CNA C and CNA D washed or sanitized their hands during incontinent care provided to Resident #16 on 4/14/2026.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #16 dated 4/14/2026 reflected she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrial fibrillation (irregular heart rhythm), major depressive disorder (persistent sadness or loss of interest in doing things), and GERD (acid reflux disease).Record review of a Quarterly MDS Assessment for Resident…

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 interviews and record review, the facility failed to develop, implement, and maintain an effective training program for 2 of 17 employees (Dietary Manager and the Activity Director) new and existing staff reviewed for training requirements. The facility failed to ensure the Activity Director was trained in effective communication, HIV, dementia, infection control and restraint reduction on hire.The facility failed to ensure the Dietary Manager was trained in falls, dementia, infection control and behavioral health on hire This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included:Record review of the personnel file for the Activity Director indicated she was hired at the facility on 04/01/2026 and did not have evidence of on hire training in effective communication, HIV, dementia, infection control and restraint reduction on hire. Record review of the personnel file for the Dietary Manager indicated she was hired at the…

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

Based on interview and record review, the facility failed to provide the required education on the rights of the residents and the responsibilities of a facility to properly care for its residents for 1 of 17 employees (CNA E) reviewed for training requirements, in that:The facility failed to ensure that annually required education was provided on the rights of the residents and responsibilities of a facility to properly care for its residents were conducted with CNA E.This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings were: Record review of the personnel file for CNA E revealed a hire date of 06/29/2024. There was no evidence of annual training since hire date on resident rights and the responsibilities of a facility to properly care for its residents. Record review of electronic records of training for CNA E indicated she initiated training on 04/15/2026, after surveyor entrance on 04/13/2026, but training was not completed.During an interview on 04/15/26 at 9:22 AM, the Human Resource Coordinator said she was…

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

Based on interviews and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation and dementia management training for 1 of 17 (CNA E) reviewed for required training.The facility did not ensure Abuse, Neglect, and Exploitation and dementia management training was completed by the CNA E during annual training for 2025. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and poor quality of care by staff with inadequate training when caring for dementia residents. Findings included:Record review of the personnel files for CNA E indicated a hire date 06/29/2024. There was no evidence that CNA E had not completed the required annual training for Abuse, Neglect, and Exploitation and dementia management. Annual training was not completed by CNA E since her hire date 06/29/2024.Record review of electronic training for CNA indicated it was initiated by CNA E on 4/15/2026 but not fully completed, after entrance of the survey team on 04/13/2026.During an interview on 04/15/2026 at 10:30…

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 interviews and record review, the facility failed to ensure the required minimum 12 hours annual in-service education was provided for 1 of 5 CNAs (CNA E) reviewed for training requirements.The facility did not provide the required 12 hours of annual in-service education to CNA F. This failure could place residents with dementia at risk of abuse, neglect, exploitation and poor quality of care by staff with inadequate training when caring for residents. The findings included:Record Review of a personnel file for CNA E indicated a hire date of 06/29/2024 and did not include the required 12 hours of annual in-service. The personnel file revealed no training for the year 2025 for Resident Rights, Abuse, Dementia, Infection Control, Effective communication, Falls, Restraints and Behavioral Health.Record review of electronic training for CNA E indicated she initiated training on 04/15/2026 after surveyor entrance on 04/1/2026 but training was not completed.During an interview on 4/15/2026 at 10:00 AM, The ADON said annual CNA training with assigned in a computer program and 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 the residents' environment remains as free of accident hazards as possible for 1 of 6 residents reviewed for quality of care. (Resident # 4)The facility failed to ensure CNA A and CNA B properly and safely transferred Resident #4 while using a mechanical lift on 3/3/2026.This failure could result in a loss of quality of life due to injuries.Findings included:Record review of an admission Record for Resident #4 dated 3/5/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, expressive language disorder (a communication disorder that affects a person's ability to express thoughts, ideas, or emotions using language), and osteoporosis (brittle bones).Record review of a care plan for Resident #4 revised 2/13/2026 indicated she had an ADL self-care performance deficit and limitation in physical mobility. Interventions for transfers indicated she required the use of a Hoyer…

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 have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 5 staff (CNA B) reviewed for nursing services.The facility failed to ensure CNA B properly and safely transferred Resident #4 while using a mechanical lift on 3/3/2026.This deficient practice could place residents at risk for injury and harm.The findings included: Record review of an admission Record for Resident #4 dated 3/5/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, expressive language disorder (a communication disorder that affects a person's ability to express thoughts, ideas, or emotions using language), and osteoporosis (brittle bones).Record review of a care plan for Resident #4 revised 2/13/2026 indicated she had…

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 1 of 5 residents (Resident #5) reviewed for infection control.The facility failed to ensure CNA A followed enhanced barrier precautions when she provided personal care that included dressing of Resident #5 on 3/3/2026.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #5 dated 3/4/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dysphagia (difficulty speaking), hypertension, and cerebral infarction (stroke).Record review of an Annual MDS Assessment for Resident #5 dated 2/9/2026 indicated she had severe impairment in thinking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews review the facility failed to ensure the resident received adequate supervision and assistive devices to prevent accidents for one (CR #1) of eleven residents reviewed for falls in that: The facility failed to provide adequate supervision and develop and implement interventions to reduce the risk of falls or injury for CR#1. This failure could affect residents who were a fall risk which could result in injury and contribute to avoidable accidents.Findings include: Record review of CR#1's face sheet dated 1/23/26 identified a [AGE] year-old male admitted on [DATE] (initial admission 6/10/24) with diagnoses including metabolic encephalopathy, lack of coordination, bipolar disorder with psychotic features, muscle weakness, muscle wasting and atrophy, wedge compression fracture of the first lumbar vertebra, and history of falls. Review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 6, indicating moderate cognitive impairment, and documented a history of falls…

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 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes, but is not limited to, seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Based on interviews and record review, the facility failed to ensure the resident was free from abuse for 1 (CR #1) of 11 residents reviewed.The facility failed to ensure that all staff were trained and knowledgeable in how to react and respond appropriately to resident behavior.The facility failed to protect the resident from physical abuse when staff used physical force during care that resulted in injury. This failure could place residents at risk for abuse, neglect, and exploitation and compromise their right to be free from harm.Record review of CR #1's face sheet dated 01/23/26 identified a [AGE] year-old male admitted on [DATE] (initial admission [DATE]) with diagnoses including metabolic encephalopathy, bipolar disorder 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 the interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the facility administrator and to other officials, including the State Survey Agency, as required by State law and established facility procedures. Federal and state regulations require all staff to recognize, report, and document any incident or allegation of abuse, regardless of intent or injury, to ensure timely investigation and protection for one (CR #1) of eleven residents reviewed related to abuse and neglect. The facility failed to report an incident on 09/01/2025 involving CR #1, in which a Certified Nurse Aide (CNA) admitted to physically grabbing the resident's arm during care, resulting in a 5 x 2.5 cm skin tear to the left forearm. This failure placed residents at risk for allegations of abuse not being promptly reported, lack of timely investigation, continued exposure to potential harm, 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 interviews and record review, the facility failed to revise and implement a comprehensive, person-centered care plan to address the resident's known and ongoing medical and nursing needs for 1 (CR #1) of 11 residents reviewed. The facility failed to identify and incorporate care plan interventions related to changes in condition and emergency response, including the use of Naloxone (Narcan), despite known risk factors.This failure resulted in staff responding to ongoing fall risk, behavioral escalation, and changes in condition without clear, individualized guidance.This failure could place residents at risk for unmet medical and nursing needs, delayed response to changes in condition, and inconsistent care. Record review of CR #1's face sheet dated 01/23/26 identified a [AGE] year-old male with diagnoses including metabolic encephalopathy, bipolar disorder with psychotic features, impaired mobility, muscle weakness, and a history of repeated falls.Record review of the 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 that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident for 1 of 11 residents reviewed for pharmacy services (CR#1). The facility failed to administer Naloxone (Narcan), as ordered for suspected opioid overdose, to CR #1 on 09/09/2025. Despite staff suspicion of possible drug use and the resident presenting with unresponsiveness, facility nursing staff did not provide the emergency medication before EMS arrival. This failure could place residents at risk for delayed emergency intervention, exacerbation of life-threatening conditions, and increased potential for physical harm.Findings include: Record review of CR#1's face sheet dated 1/23/26 identified a [AGE] year-old male admitted on [DATE] (initial admission 6/10/24) with diagnoses including metabolic encephalopathy, lack of coordination,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 6 (Resident #1) residents reviewed.The facility failed to include Resident #1's PICC line (intravenous access to deliver medications into the blood stream) on her care plan.This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.The findings included:Record review of an admission Record for Resident #1 dated 12/17/2025 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of UTI (infection in the urinary tract), type 2 diabetes, vascular dementia (decreased blood flow to areas of the brain), hypertension, and hemiplegia (paralyzed on one side of the body). Record review of active physician orders for Resident #1 dated 12/17/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #1) reviewed for parenteral fluids.The facility failed to manage Resident #1's PICC line (intravenous access to deliver medications into the blood stream) dressing per professional standards and per the physician's order.This failure placed residents at risk of developing an infection.Findings included:Record review of an admission Record for Resident #1 dated 12/17/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of UTI (infection in the urinary tract), type 2 diabetes, vascular dementia (decreased blood flow to areas of the brain), hypertension, and hemiplegia (paralyzed on one side of the body). Record review of active physician orders for Resident #1 dated 12/17/2025 indicated an order to change PICC/Midline…

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 necessary services to maintain grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLS. The facility failed to provide hair care to Resident #1 which resulted in a large hair mat at the back of her head that had to be cut out on 11/11/25. The facility failed to provide showers or baths to Resident #1 in compliance with their shower/bath schedule. This failure could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings included: Record review of Resident #1's face sheet dated 11/25/25 indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included cognitive communication deficit (difficulties in communication that arise from underlying cognitive impairments), muscle wasting and atrophy (thinning or loss of muscle…

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 clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of clinical records. Facility staff failed to document Resident #1's ADL for baths or showers and hair care or refusals. This failure could place residents at risk of not receiving care and services to meet their needs. Record review of Resident #1's face sheet dated 11/25/25 indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included cognitive communication deficit (difficulties in communication that arise from underlying cognitive impairments), muscle wasting and atrophy (thinning or loss of muscle mass), Parkinson's (movement disorder), diabetes (condition that affects blood sugar levels), dementia (decline in cognitive function), major depressive disorder (mood disorder that causes a persistent…

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 to ensure the accurate administration of medications for 1 (Resident #2) of 16 residents reviewed for pharmacy services. The facility failed to administer ordered medications for Resident #2 on 9/3/25, 9/6/25, 9/9/25, 9/17/25, 9/30/25, 10/6/25, 10/7/25, 10/13/25, 10/14/25, 10/29/25, 10/30/25, and 11/1/25. This failure could place the residents at risk of a decline in health, and decreased quality of life.Findings included:Record review of a facility face sheet dated 11/5/25 for Resident #2 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: acute and chronic respiratory failure with hypoxia (a condition where you don't have enough oxygen or too much carbon dioxide in your body), type 2 diabetes (uncontrolled blood sugar), and hypothyroidism (Underactive thyroid - a condition where the thyroid gland does not produce enough thyroid hormones, leading to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 3 of 10 residents (Resident #2, Resident #17, and Resident #13) and 3 of 5 staff (CNA H, LVN F, and MDS Coordinator) reviewed for infection control. The facility failed to ensure CNA H changed her gloves and washed/sanitized her hands during incontinent care provided to Resident #2 on 11/4/2025.The facility failed to ensure LVN F changed her gloves when she changed from dirty to clean during wound care provided to Resident #17 on 11/4/2025.The facility failed to ensure the MDS Coordinator wore appropriate PPE for enhanced barrier precautions when wound care was provided to Resident #13 on 11/20/2025.These failures could place residents at risk of exposure to infectious diseases due to improper infection 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 interview and record review the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to the participation of the resident and the resident representative for 1 of 10 residents (Resident #2) reviewed for care plans.The facility failed to ensure Resident #2, and her representative were invited and attended the resident care plan conferences.This failure could place residents at risk of not receiving the care and services to meet their needs.Findings include:Record review of an admission Record for Resident #2 dated 11/5/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder (persistent sadness or loss of interest in doing things), type 2 diabetes, and hypertensive heart disease with heart failure (high blood pressure that makes it difficult for the heart to pump blood through the body). Record review of a Significant Change MDS assessment dated [DATE] for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from bedside and toileting and bathing facilities for 2 (Hall 200 and 300) of 4 hallways and 9 of 9 (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) residents reviewed for call light response. The facility failed to ensure Hall 200 and 300's call lights were visible and audible to staff and failed to provide an alternate method for residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) to call for assistance. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.Findings include:1. Record review of a facility face sheet dated 7/30/2025 for Resident #2 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with hemiplegia and Hemiparesis (muscle weakness or partial 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.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen. The facility failed to ensure the temperature for the dish machine was at the appropriate temperature of 120 degrees according to the manufacturer's guidelines on 2/24/2025. The facility failed to remove 9 cups of yogurt from the refrigerator that were dated 2/23/2025 on 2/24/2025. The facility failed to ensure a box of white onions, a box of cucumbers and tomatoes were removed from the refrigerator when they had white, hairy, and black substances present on 2/24/2025. These failures could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included: During an initial observation on 2/24/2025 at 8:33 AM, the DM, DA B and [NAME] were present in the kitchen. The dish machine was checked by DA B who ran a cycle three times and the temperature would not reach 120 degrees as per manufacturer's guidelines. The temperature gauge at the top of the dish machine would not go past 108 degrees. DA B said…

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 maintain an effective pest control program and ensure it was free of pests for 1 of 1 Kitchen reviewed for pest control. The facility failed to ensure an effective pest control program was in place to keep roaches out of the kitchen from 2/24/2025-2/25/2025. This failure could place residents at risk for injury due to an ineffective pest control program at the facility. Findings included: During an observation on 2/24/2025 at 3:47 PM, in the kitchen, 2 roaches crawled up the wall by the hand sink. The DM said pest control visited the facility monthly and sprayed the kitchen. During an observation on 2/24/2025 at 4:14 PM, 1 roach crawled on the floor by the 3-compartment skin and dish machine. During an observation on 2/24/2025 at 4:24 PM, 1 roach crawled on the recipe binder that was less than a foot from the robo coupe (blender) on the prep table. DM notified and took the binder and shook it out in the garbage disposal and turned it on and then brought back the binder and placed it back on the prep table…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 3 of 6 residents reviewed for new admissions (Resident #167, #174, and #175). The facility failed to complete baseline care plans within 48 hours of admission for Residents #167, #174, and #175. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a facility face sheet dated 2/25/25 for Resident #167 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of cellulitis (skin infection). Review of an electronic medical record for Resident #167 indicated that no baseline care plan was completed. Review of a Nursing Home PPS MDS assessment dated [DATE] for Resident #167 indicated she had a BIMS score of 14 indicating that she was cognitively intact. She required partial/moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 3 of 6 residents (Resident #9, Resident #117, and Resident #175) and 3 of 5 staff (CNA A, CNA D, and LVN G) reviewed for infection control. The facility failed to ensure CNA D washed or sanitized her hands when passing out meal trays to residents on Hall 100 on 2/24/2025. CNA A did not wear appropriate PPE for enhanced barrier precautions when care was provided to Resident #117 on 2/24/2025. The facility failed to implement contact isolation per physician orders for Resident #175 from 2/13/25 until 2/25/25. CNA D and LVN G failed to wear appropriate PPE for enhanced barrier precautions when providing care to Resident #9 on 2/27/25. These failures could place residents at risk of exposure to infectious diseases…

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

Based on interviews and record review, the facility failed to ensure employees received the required training effective communications for 6 of 15 new employees (LVN M, LVN N, SW, CNA O, CNA P, CNA Q) reviewed for training. The facility did not ensure an effective communication training was completed on hire for LVN M, LVN N, SW, CNA O, CNA P, CNA Q. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of employee files indicated the following staff had not completed training during orientation on effective communication: * LVN M, hire date 3/16/24; * LVN N, hire date 12/03/24; * SW, hire date 11/21/24; * CNA O, hire date 12/02/24; * CNA P, hire date 10/01/24; and * CNA Q, hire date 02/12/2025. During an interview on 2/27/25 at 9:00 am the Administrator said she did not know all these trainings were required. During an interview on 2/27/25 at 1:38 pm the DON said the ADON had been responsible in the past for staff training, but she (DON) would now be responsible for it. The DON said staff…

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

Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 5 of 15 staff (LVN N, SW, CNA O, CNA P, CNA Q) reviewed for training. The facility failed to ensure infection prevention and control training was provided to LVN N, SW, CNA O, CNA P, CNA Q on hire. This failure could place residents at risk of the spread of illness due to lack of staff training. The findings were: Record review of employee files indicated the following staff had not completed training during orientation on infection control: * LVN N, hire date 12/03/24; * SW, hire date 11/21/24; * CNA O, hire date 12/02/24; * CNA P, hire date 10/01/24; and * CNA Q, hire date 02/12/2025. During an interview on 2/27/25 at 9:00 am Administrator said she did not know all these trainings were required. During an interview on 2/27/25 at 1:38 pm DON said the ADON had been responsible in the past for staff training, but she (DON) would now be responsible for it. DON said staff could be at risk of putting…

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 interviews and record review, the facility failed to ensure CNAs completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 3 of 5 CNAs (CNA O, CNA P, and CNA Q) reviewed for training. The facility did not ensure ANE, and dementia management trainings were completed by CNA O, CNA P, and CNA Q during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee files indicated: CNA O, hire date 12/02/24, had not completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings during orientation. CNA P, hire date 10/1/24, had not completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings during orientation. CNA Q, hire date 2/12/25, had not completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings during orientation. During an interview on 2/27/25 at 9:00 am Administrator said she did not know all…

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 interviews and record review, the facility failed to provide mandatory effective behavioral health training for 6 of 15 employees (LVN M, LVN N, SW, CNA O, CNA P, CNA Q) reviewed for training. The facility failed to ensure effective behavioral health training was provided to LVN M, LVN N, SW, CNA O, CNA P, CNA Q S on hire. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of LVN M's personnel file revealed a hire date of 3/16/24 and she had not completed on hire behavioral health training as required by policy and regulation. Record review of LVN N's personnel file revealed a hire date of 12/3/24 and she had not completed on hire behavioral health training as required by policy and regulation. Record review of SW's personnel file revealed a hire date of 11/21/24 and she had not completed on hire behavioral health training as required by policy and regulation. Record review of CNA O's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for residents for 1 of 24 residents (Resident #29) observed for resident environment. The facility failed to ensure the privacy curtain and a wheelchair in the room of Resident #29 was clean and without odors on 2/24/2025. This failure could place residents at risk for an unsanitary environment. Findings included: Record review of an admission Record dated 2/25/2025 for Resident # 29 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, PBA (a medical condition that causes sudden and uncontrollable crying or laughing), age related osteoporosis (brittle bones), and expressive language disorder (a communication disorder that causes difficulty expressing spoken language). Record review of a Quarterly MDS assessment dated [DATE] for Resident #29 indicated she was rarely/never understood. She required the use of a wheelchair. She was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 3 residents reviewed for misappropriation of property. (Resident #17) The facility failed to prevent a diversion (misappropriation) of Resident #17's Hydrocodone-Acetaminophen 10-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on December 31, 2024. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings include: Record review of an undated face sheet for Resident #17 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Unspecified Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Urinary Tract Infection, Cognitive Communication Deficit, Repeated Falls. Record review of an Annual MDS dated [DATE] for Resident #17 indicated that he had a BIMS score of 09, indicating that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #4) reviewed for PASARR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #4 had a new level 1 PASARR completed with a new diagnosis of major depressive disorder added on 10/28/2024. These failures could place residents at risk of not receiving the needed PASARR services to meet their individual needs and could result in a decreased quality of life. The findings were: Record review of an admission Record dated 2/26/2025 for Resident #4 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of adjustment disorder with depressed mood (a condition where a person had depression as a result of a life change or stress), major depressive disorder (a mood 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 a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 2 of 6 residents (Resident #1 and #173) reviewed for ADL care. The facility failed to follow care plan for Resident #1 and assist her with showers on 2/17/25, 2/21/25, and 2/25/25. The facility failed to ensure Resident #173 had clean and trimmed nails on 2/24/25 and 2/25/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: Record review of a facility face sheet dated 2/26/25 for Resident #1 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision with smoking materials to prevent accidents for 1 of 8 residents (Resident #27) reviewed for accidents and hazards. The facility failed to ensure Resident #27 returned his lighter and cigarettes to the staff when returning from smoking. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: Record review of an admission Record for Resident #27 dated 2/27/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, pneumonia (lung infection), and bipolar (extreme mood swings). Record review of a Quarterly MDS Assessment for Resident #27 dated 1/13/2025 indicated he did not have any impairment in thinking with a BIMS score of 15. He was independent with all ADLs. Record review of a care plan for Resident #27 dated 11/11/2024 indicated he was a smoker. Interventions included he…

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

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services for 2 of 12 months (January 2025 and February 2025) reviewed for pharmacy services. The facility failed to document the required number of 2 witness signatures for drug destruction on 1/28/2025 and 2/20/2025. This failure could put residents at risk for misappropriation and drug diversion. Findings included: Record review of facility drug destruction records for the last 12 months (3/2024 to 2/2025) reflected that on 1/28/2025 the cover page and the attached page were only signed by the DON and the Pharmacist and did not include any additional witness signatures. Record review of cover page dated 2/20/2025 was signed by the Pharmacist only with no witness signatures. During an interview on 2/27/2025 at 9:15 AM, the DON who said the drug destruction sheets were normally signed by the Pharmacist, ADON and herself. She said in January 2025…

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 drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 26 residents (Resident #5) reviewed for medication storage. The facility did not ensure Nystatin powder was not stored at the bedside for Resident #5 on 2/24/25. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: Record review indicated that Resident #5 was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis includes congestive heart failure, hypertension, cognitive communication deficit, and cognitive decline. Record review of a quarterly MDS dated [DATE] indicated that Resident #5 had a BIMS score 13 indicating that the resident has cognitively intact. She required moderate to maximal assistance for all ADL's. Resident was continent of bowel and bladder.…

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition with the pilot light staying lit and allowing gas to leak on 2/24/2025. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner. Findings included: During an observation and interview on 2/24/2025 at 8:40 AM, the DM lit the burners on the stove. 1 of the 6 burners (front left burner) did not light using the pilot light and then would not light with a lighter. She said she would report this to the Maintenance Supervisor. During an interview on 2/25/2025 at 3:00 PM, the Maintenance Supervisor said she had been employed at the facility for 5 years and been in maintenance for 3 months. She said she kept a maintenance logbook in the past at the nurse station, but it always would come up missing, so the facility no longer had a book to log 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.

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 and kitchen sanitation. The facility failed to ensure the DM and [NAME] wore a hairnet effectively to cover all of their hair on 8/27/2024. The failure could place residents at risk of foodborne illness and food contamination. Findings included: During an observation in the kitchen on 8/27/2024 at 9:20 AM, revealed the DM was wearing a hair net that did not completely cover her hair. The DM had a long ponytail that went down her back hair that was not covered by the hairnet. During an observation in the kitchen on 8/27/2024 at 9:30 AM, revealed the [NAME] was wearing a hair net that did not completely cover her hair. She had hair that was exposed on the sides of her head by her ears and at the back of her head. During an observation and interview on 8/27/2024 at 9:35 AM, the DM said all staff who worked in the kitchen should wear a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, 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 1 of 6 residents (Resident #6) and 1 of 8 staff (CNA A) reviewed for infection control. CNA A did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #6 on 8/27/2024. The failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: Record review of an admission Record dated 8/28/2024 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of other psychotic disorder (lose touch with reality), abnormalities of gait and mobility (difficulty walking) and hypertension. Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 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 interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one of four quarters for 2023 (Quarter 2) reviewed for sufficient nursing staff. The facility did not have sufficient staff on weekends according to the PBJ report for Quarter 2 2023 (January 1 through March 31). This failure could place residents at risk of diminished quality of life and quality of care. Findings included: Record review of the CMS PBJ reports Quarter 2 2023 (January 1 through March 31) indicated: the facility had a 1-star staffing rating. Record review of CMS PBJ report for Quarter 2 2023 (January 1 through March 31) indicated the facility had excessively low weekend staffing. During an interview on 01/10/24 at 09:20 a.m., the Administrator said his start date at the facility was 04/03/23 so he had no knowledge regarding the prior quarterly PBJ report regarding staffing. During an interview 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 interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 12 of 12 months (October 2022 through October 2023) and failed to ensure a registered nurse served as DON on a full-time basis for 3 of 3 months (November 2023 through January 2024) reviewed for RN coverage. The facility did not have the required eight consecutive hours of RN coverage for 15 days in October 2022, 25 days in November 2022, 7 days in December 2022, 13 days in January 2023, 6 days in February 2023, 8 days in March 2023, 8 days in April 2023, 8 days in May 2023, 6 days in June 2023, 2 days in July 2023, 7 days in August 2023, and 5 days in September 2023. The facility did not have an RN serving as full-time DON in November 2023, December 2023, and January 2024. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included: Record review of PBJ Staffing Data Report for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 14 residents whose medications were reviewed. (Resident #25) Resident #25 received Humalog insulin when the resident's blood glucose was outside parameters set by the physician. This failure could place the residents who were prescribed insulin to lower blood glucose which included parameters at risk of adverse side effects from medications. Findings included: Record review of physician orders dated January 2024 indicated Resident #25, admitted [DATE], was a [AGE] year old female with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood). The parameters set by the physician orders included Humalog insulin (used to lower blood glucose) - inject 3 units before meals, with parameters to give only if blood glucose level is above 400. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #25 had a BIMS score of 09…

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 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 14 residents reviewed for infection control. (Resident #'s 5 and 25) LVN A did not don appropriate PPE before entering Resident #5's COVID-19 (a disease caused by a virus named SARS-COV-2 causing respiratory symptoms, which is very contagious and spreads quickly) isolation room. The facility did not ensure proper infection control procedures for the sanitizing the bed when Resident #25 was removed from isolation. These failures could place the residents at risk of contracting an infectious disease and a decline in health. Findings included: 1. Record review of physician orders dated 01/10/24 indicated Resident #5, admitted [DATE], was a [AGE] year-old female with a diagnosis of COVID-19. An order 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 interview and record review, the facility failed to provide services as outlined by the comprehensive care plan, to meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #25) of 14 residents reviewed for following physician's orders. The facility failed to implement Resident #25's care plan for when her blood glucose was above 450 for 5 days and did not notify her physician in December 2023. (12/07/23, 12/11/23, 12/12/23, 12/17/23 and 12/20/23). The failure placed residents, who required blood glucose monitoring, at risk for diabetic complications due to delayed physician intervention. Findings included: Record review of Resident #25's admission record indicated she was admitted on [DATE], was 51- years- old with diagnoses which included diabetes (too much sugar in the blood). Record review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 14 residents reviewed for ADL care. (Resident #8) The facility did not ensure Resident #8's fingernails were trimmed. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of the physician orders dated January 2024 indicated Resident #8 was a [AGE] year-old male, admitted on [DATE], with diagnoses of paraplegia (paralysis of the legs and lower body) and contractures (a shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints) of his right and left hands. Record review of the most recent MDS assessment dated [DATE] indicated Resident #8 had a BIMs score of 13 (score indicated resident was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #12) of 1 resident reviewed for enteral feeds. The facility failed to ensure Resident #12's enteral feed was properly labeled with the type of formula, date and time it was hung, and the rate of administration. This failure could place residents at risk of not receiving the proper nutritional requirements prescribed by the physician. Findings included: Record review of Resident #12's admission record dated 01/08/24 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included a gastrostomy (an opening into the from the abdominal wall, surgically made for introduction of enteral feeding). Record review of Resident #12's significant change MDS assessment, dated 08/23/23, indicated his BIMS score was 02 indicating his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 14 residents reviewed for respiratory care. (Resident #'s 1 and 6) The facility did not ensure Resident #1's and #6's oxygen filters were clean and free of dust and debris. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life. Findings included: 1. Record review of physician orders dated 01/10/24 indicated Resident #1, admitted [DATE], was a [AGE] year-old female with a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The resident was ordered oxygen 2 liters by nasal cannula continuously with 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.