Twin Pines Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed for storage of drugs and biologicals.The facility failed to ensure the 100-hall medication cart was locked and secured.These deficient practices could place residents at risk of medication misuse or drug diversion.The findings included: During an observation and interview on 2/19/26 at 7:23 a.m. revealed the 100-hall medication cart was left unlocked and unattended. Interview with MA I revealed the unlocked medication cart observed on the unit was assigned to RN C. MA I stated, RN C was in a resident room assessing a resident. During an interview on 2/19/26 at 7:26 a.m., RN C stated she was in a room assessing a resident who had fallen. RN C stated she should not have left the 100-hall medication cart unlocked and unattended because other residents or visitors could gain access to the cart and take medications that did not belong to them which could result in 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 provide or obtain laboratory services to meet the needs of its residents for 1 of 4 residents (Resident #66) reviewed for laboratory services: The facility failed to obtain a digoxin drug level (digoxin is a medication used to manage atrial fibrillation [rapid heart rate] or heart failure; obtaining digoxin levels determines therapeutic effects and toxicity effects) for Resident #66 as ordered by the physician. This deficient practice could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed.The findings included: Record review of Resident #66's face sheet dated 2/19/26 reflected an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease without heart failure, hyperlipidemia (high cholesterol), hypertension (elevated blood pressure) and atrial fibrillation (irregular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and #2) reviewed for comprehensive person-centered care plans. 1.The facility failed to ensure a care plan was developed to address Resident #1 required a divided plate (a durable 3 or 4-section that have high sides and partitions to aide one-handed scooping, prevent spilling, and assist those with arthritis [joint inflammation] or dementia). 2.The facility failed to ensure a care plan was developed to address Resident #2 required a mechanical soft diet and a divided plate. These deficient practices could place residents at risk of not receiving the type of care required and result in unmet needs.The findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure comprehensive care plan was developed within seven days of the completion of the comprehensive assessment and were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 resident of 5 residents (Resident #3) reviewed for comprehensive care plans. The facility failed to revise Resident #3's comprehensive person-centered care plan after her quarterly MDS assessment to reflect she required moderate assistance with the ADL of eating, needed a mechanically altered diet, magic cup with lunch and pureed meat with gravy. This deficient practice could place residents at risk of a lack of assistance with care. Record review of Resident #3's electronic face sheet dated 02/06/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: fracture of lower end of left femur a break or injury to the thighbone,…

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 care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure the MDSN, and the ST knocked on Resident #1's door before entering the resident's rooms. This failure could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress. Findings included:Record review of Resident #1's face sheet, dated 11/26/2025, revealed s a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included muscle weakness, difficulty in walking, lack of coordination, cognitive communication deficit (problems with communication), malaise (feeling of general discomfort), insomnia, (difficulty sleeping) major depressive disorder (mental health disorder characterized by…

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 bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 2 of 14 residents (Resident #2 and Resident #3) reviewed for resident call system . The facility failed to provide a working communication system that was easily at reach, which would allow Resident #2 and Resident #3 the ability to safely call staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings include:Resident #2 Record review of Resident #2's face sheet, dated 11/26/2025, revealed s an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia (memory, thinking, difficulty), chronic obstructive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 02/11/2025, for a fall with major injury that occurred on 01/12/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated 04/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #1's Diagnosis Report, dated 04/17/2025, reflected a primary and admitting diagnosis of Hemiplegia (partial to complete loss of muscle function of one side of the body) and Hemiparesis (muscle weakness of one side of the body) following an unspecified cerebrovascular disease (a group of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to transport Resident #1 to a scheduled appointment with an oncologist, MD F as ordered on 02/10/2025. This failure could place residents at risk for not receiving appropriate care and treatment and or a decline in their health. Findings included: Record review of Resident #1's admission Record, dated 02/13/2025, reflected Resident #1 was a [AGE] year-old male. He was admitted on [DATE]. MD G was noted as Resident #1's attending physician. Record review of Resident #1 Diagnosis Report, dated 02/13/2025, reflected Resident #1 was noted to have diagnoses including secondary malignant neoplasm (a cancerous tumor either caused by a prior cancer treatment or a tumor unrelated and in a new…

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 residents have a right to personal privacy for 2 of 2 residents (Residents #70 and #78) reviewed for privacy, in that: 1. MA M did not close the computer screen exposing Resident #70's personal medical information. 2. LVN K and LVN L did not completely close Resident #78's privacy curtain while providing wound care. This failure could place residents at-risk of loss of dignity due to lack of privacy. The findings included: 1. Record review of Resident #70's face sheet dated, 12/4/24, revealed a [AGE] year old female with an admission date of 2/27/23, with diagnoses that included: Dementia (is the loss of cognitive functioning thinking, remembering, and reasoning), Bipolar disorder (mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), and Major Depression Disorder (is a mood disorder that causes a persistent feeling of sadness and loss of…

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

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, in that: 1. There were no foot-operated waste baskets near hand-washing station. 2. A tray of glasses filled with tea were uncovered. 3. Dietary Aide H was not wearing a hairnet that fully covered her hair. 4. Individual packets of salt and artificial sweetener were in the pantry floor. 5. An oily liquid substance was in the pantry floor under a container of fry oil. 6. Flour was in the pantry floor under a container of flour. 7. Dusty debris on the lower shelf of the food preparation counter. These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. The findings were: Observation on 12/03/2024 at 10:00 a.m. revealed there were no foot-operated waste baskets near the hand-washing sink. During an interview with Dietary Aide G on 12/03/2024 at 10:00 a.m., Dietary Aide G confirmed there were no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 (Hallway A and Hallway E) of 7 resident hallways reviewed for environmental concerns. 1. On resident hallway-A the facility failed to repair: in room [ROOM NUMBER] both sides of the interior bathroom door had 4 inch wood cracks on the bottom of the door, in room [ROOM NUMBER] the phone jack was dislodged from the wall between beds A & B and there was a 2 foot black scrape mark behind the head board of bed A, in room [ROOM NUMBER] there was a black scrape mark on the wall besides the B-bed which measured 2 x2 feet, in room [ROOM NUMBER] there were 2 penetrations on the wall besides the B-bed which measured 7x5 and 1 x 1.5' and at the end of hallway-A there were water marks on 4 of the 2x2' ceiling tiles and 2 other ceiling tiles were removed from the ceiling. 2. On resident hallway-E the facility failed to repair: in room [ROOM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observations, Interviews, and Record review, the facility failed to ensure that residents 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 other residents for 1 out of 3 (Resident #5) reviewed for call light. The facility failed to ensure Resident #5's call light was within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being. Findings included: Record review of Resident #5's face sheet dated 12/3/24 revealed [AGE] year old female admitted to the facility on [DATE]. Resident #5 had diagnosis that included Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform daily tasks), Insomnia (sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep), and Seizures (a burst of uncontrolled electrical…

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 had a right to a safe, clean, comfortable, and homelike environment for 1 (Resident #77's room) of 80 resident rooms reviewed, in that: A foul odor was emanating from the restroom of Resident #77's room. This failure could result in psychosocial harm due to diminished quality of life. The findings were: Record review of Resident #77's face sheet, dated 12/06/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes Mellitus, Hyperlipidemia, and Anemia. Record review of Resident #77's Quarterly MDS, dated [DATE], revealed a BIMS score of 09 which indicated moderate cognitive impairment. Record review of Resident #77's care plan, initiated 08/24/2024, revealed [Resident #77] to remain in facility for long term care, with a goal, [Resident #77's] needs will be met during this review period. Observation on 12/03/2024 at 10:40 a.m. revealed the presence of a foul odor…

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 a baseline care plan including the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 1 (Resident #259) of 28 residents reviewed, in that: Resident #259's baseline care plan did not include his allergies or his physician-prescribed diet. This failure could result in improper care. The findings were: Record review of Resident #259's face sheet, dated 12/05/2024, revealed he was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease, Hyperlipidemia, and Chronic Kidney Disease. Record review of Resident #259's clinical record as of 12/05/2024, revealed the resident was allergic to the medications Atorvastatin, Flomax, and Tramadol. Further review revealed the resident's physician ordered a regular diet with regular texture and regular consistency on 11/26/2024. Record review of Resident #259's baseline care plan, dated 11/26/2024,…

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 review and revise Resident Care Plans after each assessment for 1 of 8 residents (Resident #42) reviewed for care plan revision and timing. The facility failed to ensure Resident #42's care plan was revised to reflect interventions made after an actual fall with injury on 09/06/2024. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls. Findings included: Review of Resident #42's face sheet dated 12/06/2024, revealed she was an [AGE] year-old woman who had an initial admission date of 01/12/2024, with a re-admission on [DATE] and diagnoses which included: Encephalopathy (damage or disease that affects brain function causing memory loss and confusion), Orthostatic Hypotension (a form of low blood pressure that happens when standing after sitting or lying down which can cause dizziness or feeling faint), unsteadiness on feet, lack of coordination 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.

Based on observations, interviews, and record review the facility failed to ensure a resident environment that remained as free of accident hazards as possible for one (Hallway A shower room) of four shower rooms observed for hazard free environment. The facility failed to ensure that the shower room on Hallway A remained a hazard free environment. This failure could place residents at risk encountering an accident hazard in the facility. Findings included: Observation on 12/3/24 at 11:50 am with AIT C and LVN E of the unlocked resident shower room on the A-hall revealed one 32 ounce bottle of K-Quat cleaning disinfectant placed on top of a standing tile ledge and second 32 ounce bottle of the same cleaning disinfectant placed inside of an unlocked standing shower cabinet. During an interview with the AIT C and LVN E on 12/3/24 at 11:55am they stated that the unsecured bottles of disinfectant could present a risk hazard to a resident who could enter the unlocked shower room and access the cleaning disinfectant for consumption. During an interview on 12/4/24 at 7:50 a.m. 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 that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 3 the residents (Resident # 18) reviewed for oxygen use. The facility failed to ensure Residents #18's, oxygen tubing and mask was bagged and stored off the floor. This failure could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: Record review of Resident #18's face sheet dated 12/03/2024 revealed a [AGE] year-old male admitted to the facility initially on 12/12/2019 and re-admitted on [DATE], and with diagnoses that included: Dementia (a group of symptoms affecting memory, thinking and social abilities) and Chronic Obstructive Pulmonary Disease (lung disease that blocks air flow and makes it difficult to breathe). Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact…

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, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls in 1 of 2 medication rooms (Annex Medication Room) reviewed for medication storage. The facility failed to ensure one unopened bottle of Latanoprost eye drops was refrigerated until opened. This failure could place residents at risk of medications not being therapeutically effective. Findings included: Observation on 12/04/2024 at 2:05 p.m. of the Annex medication room with LVN-I present, revealed one bottle of Latanoprost 0.0005% solution for Resident # 2 stored in a plastic bag on the medication room counter, at room temperature. The label on the bottle read Refrigerate until opened. The bottle felt warm (room temperature), not cold as if it had recently been taken out of the refrigerator. During an Interview with LVN-I on 12/04/2024 at 2:10 p.m., LVN-I confirmed the bottle of Latanoprost for Resident #2 was unopened and had been found on the counter at room…

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 have sufficient nursing staff with the appropriate competencies and skills sets 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, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 out of 23 days (4/3/24, 4/4/24, 4/8/24, 4/9/24, 4/14/24, and 4/18/24) reviewed for sufficient nursing staff. The facility failed to have sufficient staff available to provide resident care on from 6:00 PM - 6:00 AM on 4/3/24, 4/4/24, 4/8/24, 4/9/24, 4/14/24 and 4/18/24. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental and psychosocial wellbeing. Findings include: Record review of the facility's Direct Care Reports reflected the number of CNAs scheduled for the 6:00 PM - 6:00 AM…

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 medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 5 errors out of 30 opportunities, which involved 2 of 4 residents (Resident #17 and Resident #18) reviewed for medication errors. 1. LVN F failed to administer medications as ordered to Resident #17 by administering Trazadone (a treatment for Depression) and Nortriptyline (a treatment for Depression)1 hour and 54 minutes after the scheduled time and not administering Melatonin (a treatment for Insomnia). 2. LVN F failed to administer a medication as ordered to Resident #18 by administering Donepezil (a treatment for Dementia) 3 hours after the scheduled time and Trazadone (a treatment for Bipolar Disorder) 2 hours after the scheduled time. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications. Findings include: 1. Record review of Resident #17's admission…

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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 medication carts (Medication cart #1, Medication cart #2, and Medication cart#3) reviewed for medication storage. 1. The facility failed to ensure the Medication cart by the nurses' station did not have a medication cup with pills sitting on top of the cart. 2. LVN F failed to ensure the Medication cart on 100 hall was not left unlocked with a resident standing next to it, while the LVN went into resident room to administer medications . 3. The facility failed to ensure the Medication cart on 300 hall was not left unlocked. 4. The facility failed to ensure the Medication cart was not left unlocked. These deficient practices could place residents at risk of medication misuse and drug diversion. Findings include: 1. Observation on 4/23/24 at 9:28 PM revealed LVN F was sitting at the nurses'…

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 each resident with a nourishing, palatable, well-balanced diet that meets met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 3 of 10 residents (Resident #7, Resident #11,, and Resident #15) reviewed for dietary services.needs, in that: 1. The facility failed to ensure Resident #7 did not received a health shake, or a red glass as prescribed on 4/22/24. 2. The facility failed to ensure Resident #11 did not received the appropriate portion size of pureed spaghetti and meatballs and a red glass on 4/20/24. 3. The facility failed to ensure Resident #15 did not received a house shake on 4/25/24 or red glass on 4/25/24 and 4/26/24 . This These deficient practices could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met. Findings includedd: 1. Record review of Resident #7's admission Record, dated 4/25/24, 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 resident medical records are kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 2 residents (Residents #5 and #15) reviewed for accuracy of records, in that: 1. The facility failed to ensure Resident #5's wound care and treatments as ordered by the physician were documented. 2. The facility failed to ensure Resident #15's wound care and treatments as ordered by the physician were documented. These deficient practices could place residents at risk for improper care due to inaccurate records. The findings were: 1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body)…

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 was treated with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 residents (Resident #5) reviewed for dignity, in that: The facility failed to ensure Resident #5 was not left exposed during wound care on 4/24/24. This failure could place residents at risk of poor self-esteem and decreased self-worth and quality of life. Findings include: Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, and Depression. Record review of 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 observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs for 2 of 2 residents (Resident #5 and Resident #15) reviewed for accommodations of needs, in that. The facility failed to ensure Resident #5, and Resident #15 were able to press the call light when assistance was needed. This deficient practice could place residents at risk of not receiving care or attention when needed. Findings included: Record review of Resident #5's admission Record, dated 4/20/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor syndrome that manifests as rigidity and/or tremors), Cognitive Communication Deficit, Muscle Weakness, Abnormal Posture, Muscle Wasting and Atrophy (decrease in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the a comprehensive care plan was developed within seven days of the comprehensive assessment and review and revise the care plan after each assessment for 1 of 12 residents (Resident #15) reviewed for care plans. The facility failed to ensure Resident #15's care plan was revised to reflect edema to left hand with elevation. These failures could place residents at risk of current needs not being met. Findings included: Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), COPD (lung diseases that block airflow and make it difficult to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 12 residents (Resident #12) reviewed for care plans. The facility failed to ensure Resident #12's care plan was revised to reflect prescribed diet and weight loss. These failures could place residents at risk of current needs not being met. Findings included: Record review of Resident #12's admission Record, dated 4/22/24, reflected the resident was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) , Malnutrition, Dysphagia (difficulty swallowing) , Cognitive Communication Deficit, Depression and GERD (digestive disease in which stomach acid or bile irritates the food pipe lining) . Record review of Resident #12's quarterly MDS assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #15) reviewed for pain management. The facility failed to adequately assess and treat Resident #15's pain. This failure could place residents at risk for unnecessary pain, discomfort and decreased quality of life. Findings include: Record review of Resident #15's admission Record, dated 4/23/24, reflected the resident was re-admitted to the facility on [DATE]. Resident #15 had diagnoses which included: Alzheimer's Disease (disease affecting memory and other important mental functions), Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure meals were prepared in a form designed to meet individual needs for 1 of 10 residents (Resident #6) reviewed for dietary services. The facility failed to ensure Resident #6 was served mechanical ground meat as prescribed. These deficient practices could place residents at risk for poor food intake, weight loss and not having their nutritional needs met. Findings included: Record review of Resident #6's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: Hypokalemia (low potassium levels in the bloodstream), Malnutrition, Weakness, Muscle Wasting and Atrophy (decrease in size or wasting away of a body part or tissue), Dysphagia (difficulty swallowing), Cognitive Communication Deficit, Altered Mental Status, Tachycardia (elevated heart rate over 100 beats per minute), Hypertension (high blood pressure) and Anxiety. Record review of Resident #6'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 ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 15 residents (Resident #16) reviewed for dietary services. The facility failed to ensure Resident #16's was not served he was allergic to and was served onions with the meal. This deficient practice could place residents at-risk by contributing to poor intake, weight loss and/or allergic reaction. Findings include: Record review of Resident #16's admission Record, dated 4/24/24, reflected the resident was re-admitted to the facility on 8/21/20. Resident #16 had diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Muscle Wasting and Hypertension (high blood pressure). Record review of Resident #16's quarterly MDS assessment, dated 2/15/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Residents #5 and #15) reviewed for infection control, in that: 1. LVN C failed to maintain infection control practices when performing wound care for Resident #5. 2. LVN C and RN B failed to maintain infection control practices when performing wound care for Resident #15. These deficient practices could place residents at risk for delayed wound healing and infection. The findings were: 1. Record review of Resident #5's admission Record, dated 4/20/24, reflected the resident was admitted to the facility on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Hemiplegia (paralysis of one side of the body) of right side, Parkinsonism (a motor…

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 accurately reflect the resident's status on the quarterly MDS for three residents (Residents #34, #90 and #104) of 24 residents reviewed for MDS assessments in that: 1. Resident #34's quarterly MDS assessment did not reflect he had a Stage IV (full thickness tissue loss with exposed bone, tendon, 1or muscle) pressure sore. 2. Resident #90's significant change MDS assessment and admission MDS assessment did not reflect she was edentulous (lacking teeth). 3. Resident #104's discharge MDS did not reflect he was discharged home. This deficient practice affects residents who receive MDS assessments and could result in missed information or inaccurate care. The findings included: 1. Record review of Resident #34's electronic face sheet dated 10/11/2023 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: hemiplegia (complete paralysis affecting one side of the body)and hemiparesis…

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, in that: 1. In the reach-in cooler, there was: a. A clear, plastic 2-qt. container of food, contents unknown, without a label or date. b. Two pies without labels or dates indicating when they were stored or a use-by date. c. An 8-oz. plastic container of food covered with disposable plastic lid without a label or date indicating when it was stored or a use-by date. d. A 2% gallon of milk, open, half-full, no label indicating the date it was open or a use-by date. 2. In the dry storage room, on a rack, there were: a. A plastic 12 qt. container with traces of flour and particles of dry cereal on the lid. Inside the container was a trace amount of flour and a clear plastic cup. b. A plastic bag of crispy rice cereal that was open, half full, rolled down and not sealed in a zip-top bag. 3. In the dish room, there were: a. Multiple trays of plastic cups and bowls stored directly on trays…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #90) reviewed for care plans, in that: Resident #90's cognitive communication deficit was not addressed in her comprehensive care plan. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record review of Resident #90s electronic face sheet dated 10/11/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for one resident (#38) out of 8 residents reviewed for comprehensive care plans in that: Resident #38's continent status was not accurately reflected on her comprehensive care plan following 2 MDS assessments. This deficient practice could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care. The findings included: Record review of Resident #38's electronic face sheet dated 10/11/2023 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: Alzheimer's disease (a progressive and irreversible condition that affects the brain and causes dementia), cardiac arrhythmia (a condition characterized by abnormal heart rhythm. This may result in either too fast or slow heart beats) and peripheral vascular disease (a condition that affects the blood vessels outside of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one resident (#70) out of 2 residents reviewed who received enteral feedings in that: Resident #70's head of the bed not kept at 30 degrees while his enteral feeding was infusing. This deficient practice affects residents who receive enteral feeding and could result in aspiration pneumonia. The findings included: Record review of Resident #70's electronic face sheet dated 10/12/2023 reflected he was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included: cerebral infarction (area of brain tissue that dies as a result of localized lack of oxygen due 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.

The facility failed to provide a therapeutic diet which was prescribed by the attending physician for two residents (#23, and #92) out of 25 residents observed during dining in that: 1. Resident #23 did not have double portions of meat on her lunch plate as was ordered by the physician. 2. Resident #92 did not have large portions of food on her plate as was ordered by the physician. This deficient practice affects residents who are ordered therapeutic diets and could result in weight or nutritional loss. The findings included: 1. Record review of Resident #23's Active Orders as of 10/10/2023 reflected she was on a regular diet, regular consistency with large portions and a fortified meal plan. Observation and review on 10/10/2023 at 12:23 p.m. revealed Resident #23 was served only one portion of barbecue ribs and her meal ticket reflected DOUBLE PORTIONS MEAT. Interview on 10/10/2023 at 12:25 p.m. with LVN D who passed out resident trays to staff as they trays came out of the kitchen, she stated the resident should have had two portions of barbecue ribs served and she went to get…

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 that the menu was followed for 1 of 1 meal observed in that: 1. The facility failed to ensure all residents received potato salad with their lunch meal on 09/28/2023. 2. The facility failed to ensure Baked Potato Salad was prepared by the recipe. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings included: Record review of the facility's, Spring/Summer 2023, Week 1, menu revealed [NAME] Sugar BBQ Chicken QTR, Baked Potato Salad, Pinto Beans, Texas Toast and Strawberry Cobbler were to be served with the lunch meal on 09/28/2023. An observation on 09/28/2023 at12:15 p.m. revealed a daily menu board in the dining room that listed [NAME] Sugar BBQ Chicken QTR, Baked Potato Salad, Pinto Beans, Texas Toast and Strawberry Cobbler for the lunch meal. The menu revealed no indication for a substitute. During an observation and interview with Resident #4 on 09/28/2023 at 12:21 p.m., revealed Resident #4's lunch tray did not include potato…

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's a right to a dignified existence for 1 of 13 residents (Resident #1) reviewed for dignity, in that: Resident #1 appeared to have urinated on himself and was observed around the facility with his pants wet between his inner upper thighs and groin area This failure could lead to residents' loss of self-esteem and feelings of dignity. The findings included: Record review of Resident #1's Face Sheet dated 09/28/2023 reflected a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnosis including: aphasia following cerebral infarction, overactive bladder, hemiplegia and hemiparesis following cerebral infarction affect right dominant side, other reduced mobility Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 99, which indicated the individual chooses not to participate, or gave a nonsensical response. Record Review of Resident #1's care plan revealed Resident #1 has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure the 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 other residents for 1 of 6 (Resident #1) residents reviewed in that: Resident #1's call light was not within reach while he was in bed. This could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. The findings included: Record review of Resident #1's Face Sheet dated 09/28/2023 reflected a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnosis including: aphasia following cerebral infarction, overactive bladder, hemiplegia and hemiparesis following cerebral infarction affect right dominant side, other reduced mobility. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 99, which 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 interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Residents #1) of 1 resident reviewed for abuse, neglect, and misappropriation of property, in that; The facility failed to report an allegation of abuse made on 09/19/2023 for Resident #1 in accordance with State law, requiring all alleged violations be reported immediately but not later than…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Resident #3) reviewed for care plans. The facility failed to ensure Resident #3's need for assistance in applying a hearing aid was on her comprehensive care plan. This failure could place residents at risk of not having their care needs met. The findings included: Record review of Resident #3's Face Sheet dated 09/28/2023 reflected a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnosis including: dementia, unspecified bilateral hearing loss (with onset date 5/19/2023), weakness. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 13, cognitively intact. Record review of Resident #3's care plan reflected 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, interviews and record reviews, the facility failed to provide an MDS assessment that accurately reflected the resident's status for one resident (Resident #4) of four residents reviewed for accurate assessments in that: Resident #4's MDS did not accurately reflect Resident #4's indwelling catheter. This failure could affect residents who receive MDS assessments and could result in disruption of continuity of care. The findings were: Record review of Resident #4's electronic face sheet, revealed the resident was [AGE] years of age and was originally admitted to the facility on [DATE]. Further review revealed Resident #4's diagnoses included: UTI (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) -Chronic Kidney Disease Stage 4 (kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood. Waste products may build up in your blood and cause other health problems)…

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 residents incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 out of 1 resident (Resident #4) reviewed for indwelling catheters. Resident #4's indwelling catheter collection bag was lying on the floor of the resident's room, not in a protective container, and was not secured to prevent pulling and/or tugging to the urethra. This failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections. The findings included: Record review of Resident #4's electronic face sheet revealed the resident was [AGE] years of age and was admitted to the facility on [DATE]. Further review revealed Resident #4's diagnoses included: -Urinary Tract Infection (UTI) (common infections that happen when bacteria, often from the skin or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 one of (Resident #4) of 5 residents observed for infection control, in that: Resident #4's catheter bag was on the floor and not contained. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #4's electronic face sheet, revealed the resident was [AGE] years of age and was admitted to the facility on [DATE]. Further review revealed Resident #4's diagnoses included: -Urinary Tract Infection (UTI) (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract. The infections can affect several parts of the urinary tract, but the most common type is a bladder infection…

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 treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for quality of care, in that The facility failed to ensure Resident #1 received a compounded steroid eye drop to his left eye from 8/01/2023 until 8/17/2023 following left eye cataract surgery. This failure could place residents of risk for not receiving proper care and treatment. The findings included: Record review of Resident #1's face sheet, dated 8/22/2023, revealed an admission date of 8/23/2021 with a readmission date of 2/10/2022 with diagnoses which included: unspecified dementia, unspecified kidney failure and major depressive disorder recurrent. Record review of a facility self-report, dated 8/17/2023, revealed the self-report was for an alleged medication error. The report stated: On 8/17/2023, at approximately 1:00 p.m., a family member…

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Residents #1) for care plan revisions, in that: The facility failed to ensure Resident #1's Care Plan was revised to include cataract surgery to the left eye. These failures could place residents at risk for not receiving care according to their needs. The findings included: Record review of Resident #1's face sheet, dated 8/22/2023, revealed an admission date of 8/23/2021 with a readmission date of 2/10/2022 with diagnoses which included: unspecified dementia, unspecified kidney failure and major depressive disorder recurrent. Record review of Resident #1's Care Plan, initialed on 2/15/2022, revealed on 8/10/2023 the care plan was revised to include that Resident #1 was on ophthalmic antibiotics with a single intervention of administer ophthalmic medications as ordered. The Care Plan did not address the left eye…

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 in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 resident (Resident #1) reviewed for accuracy of medical records in that: The facility failed to document when Resident #1 left the facility or returned to the facility for left eye cataract surgery and failed to obtain and upload documents related to left eye cataract surgery into the permanent medical record. This failure could place residents at risk for inadequate care due to incomplete medical records. The findings included: Record review of Resident #1's face sheet, dated 8/22/2023, revealed an admission date of 8/23/2021 with a readmission date of 2/10/2022 with diagnoses which included: unspecified dementia, unspecified kidney failure and major depressive disorder recurrent. Record review of Resident #1's Care Plan, initiated on 2/15/2022, revealed on 8/10/2023 the care plan was revised…

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.