Avamere Rehabilitation Of Shoreline

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate supervision and interventions were implemented to manage aggressive behaviors for 1 of 3 residents (Resident 3) reviewed for resident-to-resident altercations. This failure had the potential to cause substantial injuries to residents, fear and a diminished quality of life. Findings included .<RESIDENT 3>Review of Resident 3's admission Minimum Data Set (MDS-a required assessment) assessment dated [DATE] showed the resident was admitted to the facility on [DATE]. The MDS assessment also showed Resident 3 had severely impaired thinking and memory. Review of the facility incident investigation dated 11/28/2025 showed Resident 3 grabbed a residents [Resident 1] left arm who was talking in the hallway with another resident [Resident 2] in the facility. The resident [Resident 1] sustained a skin tear when Resident 3 grabbed their left arm. The skin tear measured 3.5 centimeters (cm-a unit of measurement) by 3.0 cm and had two bruises on 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 interview and record review, the facility failed to ensure notification about medication changes was provided to 1 of 3 residents (Resident 1), reviewed for changes in medication. The failure to notify Resident 1 that the medication Potassium Chloride (medication used to prevent and treat low potassium levels in the blood) would not be administered for thirteen days placed Resident 1 at risk for lack of knowledge about their medical condition and a diminished quality of life.Findings included . A review of the admission Minimum Data Set (MDS-an assessment tool) dated 09/23/2025, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis that included heart failure and insufficient kidney (filters that clean the blood by removing waste and extra fluid) function. The MDS further showed the resident had intact thinking and memory. In an interview on 11/25/2025 at 1:01 PM, Resident 1 stated, I did not know that the medication I took for Potassium was turned off [stopped], I know I did not…

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 follow physician's orders and failed to ensure staff documented treatments in accordance with professional standards for 1 of 1 resident (Resident 1), reviewed for treatment administration. These failures placed the residents at risk for unmet care needs, negative outcomes, and a diminished quality of life.Findings included .Review of the facility's policy titled, Administering Medications, dated April 2019, showed that Medications are administered in a safe and timely manner, and as prescribed. The policy showed, The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones. The policy further showed, Topical medications used in treatments are recorded on the resident's treatment record (TAR [Treatment Administration Record]).On 11/13/2025 at 1:17 PM, Staff D, Registered Nurse, stated nursing staff were responsible for following medication/treatment orders. Staff D stated…

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 a Licensed Practical Nurse (LPN) had the appropriate competencies, skills set and proficiencies to assess/evaluate wound care for 1 of 1 nursing staff (Staff E), reviewed for competent nurse staffing. This failure placed the residents at risk for unmet care needs, inaccurate wound assessments, and adverse outcomes.Findings included .Review of facility's policy titled, Skin and Wound Monitoring and Management, dated August 2024, showed A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to:1) Measuring the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g./ pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alteration6)…

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 conduct a thorough investigation and to take appropriate corrective action for 1 of 3 residents (Resident 3), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.Findings included .Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events .Federal law requires the nursing home to do a thorough investigation of the incident. In order for a facility to provide evidence of the thoroughness of the investigation the information must be recorded. It showed that a thorough investigation may require two phases of fact gathering which included phase one, initial investigation (within the first 24 hours) and phase two, extended investigation (after the first 24 hours). It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards of practice to ensure a clinical assessment was completed timely for a change of condition (a sign that something might be wrong and needs attention) for 1 of 3 residents (Resident 3), reviewed for assessment of care services. This failure placed the resident at risk of receiving delayed care and for potential negative outcomes.Review of the facility's policy titled, admission Assessment and Follow Up: Role of the Nurse, revised in September 2012, showed that The following information should be recorded in the resident's medical record: 1. The date and time of the assessment was performed and showed that reporting included report other information in accordance with facility policy and professional standards of practice.Review of a electronic health record showed Resident 3 admitted to the facility on [DATE]. Review of the facility's document titled, Online Incident Report Facility/Agency Information, dated 07/08/2025,…

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 observation, interview, and record review the facility failed to ensure a therapeutic diet was provided as ordered for 2 of 3 residents (Residents 1 & 2), reviewed for therapeutic diets. This failure had the potential to cause unwanted weight gain, a decline in medical conditions, and a diminished quality of life. Findings included.Review of the facility's policy titled, Diets Available on the Menu, Revised June 2019 showed, Prescribed diets are provided to deliver nutrition for residents in the facility. In order to define and standardized, diet orders will be interpreted as follows to comply with the [facility name] approved diet manual and/or to enhance choices & quality of life while meeting the current resident nutrition needs.RESIDENT 1Review of Resident 1's Electronic Health Record (EHR) printed on 07/18/2025 showed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes (A disease that occurs when your body cannot use insulin - is a hormone that helps your body use…

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 expired foods were discarded for 1 of 1 refrigerator (Solarium Room Residents' Refrigerator), and failed to ensure dishwasher temperatures were maintained within the required ranges for 1 of 1 dishwasher, reviewed for food service safety. In addition, the facility failed to follow reheating food requirements for 1 of 1 (Staff L). These failures placed all residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and a diminished quality of life. Findings included . Review of the facility's policy titled, Personal Food Storage, updated in [DATE], showed, food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored by designated facility staff for food safety .The manufacturer's use by/expiration date supersedes any facility labeled use by date. Review of the facility…

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 were evaluated and assessed, and/or physician orders were obtained for safe administration of medication for 5 of 19 residents (Residents 30, 34, 38, 10 & 5), reviewed for self-medication administration. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Self-Administration of Medications, revised in September 2004, showed that the facility would allow residents to self-administer medications if they choose. If the resident wishes to self-administer their medications, the Resident Care Manager (RCM) will evaluate potential by using the self-medication review form. If the RCM determines the resident can carry out this task in a safe and prudent manner, the physician will be notified, an order obtained, and the resident will be placed in a…

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

Based on observation, interview and record review, the facility failed to ensure resident rooms were maintained for 4 of 19 residents (Residents 29, 13, 269 & 31), reviewed for environment. The failure to ensure resident rooms were free from broken light switches and soiled privacy curtains placed residents at risk for a less than homelike environment and a diminished quality of life. Findings included . RESIDENT 29 Observations on 05/13/2025 at 2:57 PM and on 05/15/2025 at 11:01 AM, showed the privacy curtains for Resident 29's room were dirty with a brown material on them. It further showed a broken pull cord above Resident 29's bed and plastic bags tied together being used as the pullcord. In an interview and joint observation on 05/15/2025 at 11:16 AM, Staff BB, Certified Nursing Assistant, stated that if they noticed something in disrepair in a resident's room, they would report to the nurse first, tell maintenance. A joint observation of Resident 29's room showed a broken pull cord above Resident 29's bed and plastic bags tied together being used as the pull cord. Staff BB…

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 transmit the resident Minimum Data Set (MDS - an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 4 of 6 residents (Residents 53, 25, 42 & 59), reviewed for transmitting MDS assessments. This failure placed the residents at risk for unmet care needs and diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11, revised in October 2024, showed all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications.…

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 accurately assess 8 of 21 residents (Residents 26, 65, 51, 30, 21, 2, 48 & 39), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], intellectual/developmental disabilities [ID/DD]), discharge status, bowel (gut) continence, oxygen, medication, urinary catheter (a flexible tube inserted into the bladder to drain urine), and bowel patterns, placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information…

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/or implement care plans for 5 of 15 residents (Residents 3, 4, 29, 51 & 39), reviewed for comprehensive care plans. The failure to develop/implement care plans for Activities of Daily Living (ADL) and urinary catheter (a flexible tube inserted into the bladder to drain urine) care placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed that the comprehensive care plan includes measurable objectives and time frames .describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. RESIDENT 3 Review of Resident 3's quarterly Minimum Data Set (MDS-an assessment tool), dated 02/11/2025, showed that Resident 3 needed substantial/maximal assistance (helper does more than half the effort)…

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 revise comprehensive care plans for 4 of 9 residents (Residents 26, 2, 30 & 32), reviewed for care plan revision. The failure to revise the care plan that included interventions for Level II Preadmission Screen and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions), use of opioid (narcotic pain medication), self-administration of medication, oxygen use, and range of motion, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed that a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. Further review…

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 necessary assistance with Activities of Daily Living (ADL) for 3 of 4 residents (Residents 3, 29 & 51), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with personal hygiene placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed that Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. RESIDENT 3 Review of Resident 3's quarterly Minimum Data Set (MDS-an assessment tool), dated 02/11/2025, showed Resident 3 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. It further showed that Resident 3 had diabetes (a group of diseases that result in too much…

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 respiratory care in accordance with accepted professional standards of practice for 4 of 5 residents (Residents 10, 38, 30 & 271), reviewed for respiratory care. The failure to label/date oxygen tubing, properly store oxygen tank, and obtain oxygen orders placed the residents at risk of respiratory infections, and related complications. Findings included . Review of the facility's policy titled, Oxygen Administration, revised in October 2010, showed, staff verify that there is a physician's order .Review the physician's orders or facility protocol for oxygen administration. RESIDENT 10 Review of Resident 10's face sheet printed on 05/12/2025, showed they were admitted to the facility on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary disease (COPD - an ongoing lung condition caused by damage to lungs) and dyspnea (difficulty breathing). Review of the May 2025 physician orders printed on 05/12/2025, showed…

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

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with the census, actual number of staff, and the hours worked for each shift for 4 of 4 days (05/12/2025, 05/13/2025, 05/14/2025 & 05/16/2025), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility. Findings included . Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2006, showed that Within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nurses directly responsible for resident care is posted in a prominent location and in a clear and readable format .The information recorded should include the actual time worked during that shift for each category and type of nursing staff and total number of licensed and non-licensed nursing staff working for 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 pharmacy services were provided in accordance with professional standards of practice to meet the needs of 4 of 6 residents (Resident 4, 30, 21 & 38), reviewed for medication management. The failure to follow physicians order and medication instruction placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings included . Review of the facility's policy titled, Administering Medications, revised in April 2019, showed, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the facility's policy titled, Oral Inhaler [portable device for administering a drug which is to be breathed in], revised in January 2023, showed that the facility would allow for safe, accurate, and effective administration 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 interview and record review, the facility failed to ensure medications with adverse side effects were adequately monitored and/or non-pharmacological interventions were provided prior to administering pain medications for 3 of 5 residents (Residents 2, 39 & 271), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medications with Boxed Warning, revised in January 2023, showed, nursing should include appropriate monitoring parameters on the resident specific care plan as appropriate. Monitoring for adverse consequences involving ongoing vigilance and may periodically involve evaluations. RESIDENT 2 Review of the February 2025 to May 2025 Medication Administration Record (MAR) showed that Resident 2 had orders for oxycodone (opioid - narcotic pain medication). Further review of the MAR showed no documentation that Resident 2 was being monitored for adverse side effects related to oxycodone use and/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 ensure expired medications and biologicals were discarded for 1 of 1 medication room (Medication Room) and for 2 of 2 crash carts (300 Hall & 400 Hall Crash Carts), reviewed for medication storage and labeling. In addition, the facility failed to properly store medications for 5 of 19 residents (Residents 30, 38, 34, 10 & 5). These failures placed the residents at risk for receiving compromised and/or ineffective biological and medical supplies. Findings included . Review of the facility's policy titled, Storage of Medications, revised in April 2020, showed that the facility stored all drugs and biologicals in a safe, secure, and orderly manner. The policy further showed that discontinued, outdated, or deteriorated medications or biologicals would be returned to the dispensing pharmacy or destroyed. Review of the facility's policy titled, Self-Administration of Medications, revised in September 2004, showed that medications may be kept 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 interview and record review, the facility failed to ensure clinical records were properly completed for 4 of 7 residents (Residents 36, 25, 2 & 30), reviewed for resident records. The failure to fill out resident forms accurately placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . RESIDENT 36 Review of a face sheet printed on 05/13/2025 showed Resident 36 was admitted to the facility on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (having excessive/persistent worry and fear). Review of Resident 36's Level I Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) dated 04/28/2025, did not show depression and anxiety disorder were…

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

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases by: 1. Not ensuring the Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually, as required. 2. Not monitoring the expiration for eyewash station solutions for 3 of 4 eyewash stations (300 Hall Nurse's Station, 500 Hall Resident Care Manager [RCM] Office, Laundry Room), reviewed for water management. 3. Not ensuring Enhanced Barrier Precautions (EBP - precautions to protect the spread of infectious organisms) were followed for 1 of 9 residents (Residents 1). 4. Not performing hand hygiene during care and treatments for 4 of 11 residents (Residents 4, 7, 23 & 38). 5. Not appropriately handling soiled linen during transport for 2 of 2 residents (Residents 2 & 19), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk of acquiring infections, related…

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 residents on urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) were provided with privacy for 2 of 6 residents (Residents 30 & 8), reviewed for dignity. This failure placed the residents at risk for decreased self-worth and a diminished quality of life Findings included . Review of the facility's policy titled, Dignity, revised in February 2021, showed that each resident would be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The document further showed that residents were to be treated with dignity and respect. Review of the facility's policy titled, [Urinary] Catheter Care, revised in August 2022, showed that the purpose of this procedure is to prevent urinary catheter-associated complications, including bladder infections. The document further showed that catheter tubing and drainage bag were to be kept off the floor. RESIDENT 30 Observation on 05/13/2025 at 4:25…

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 an updated guardianship letter was readily available in medical records and accessible to staff for 1 of 4 residents (Resident 29), reviewed for Advanced Directives (a written instruction, such as a living will or durable power of attorney for health care). This failure placed the resident and/or their representative at risk of losing their right to have their preferences honored to receive care according to their choice. Findings included . Review of Resident 29's guardianship letter signed/dated on [DATE] showed it was effective until [DATE]. Further review showed no documentation that the facility attempted to have an updated guardianship letter in Resident 29's Electronic Health Record (EHR). In an interview and joint record review on [DATE] at 2:36 PM, Staff A, Administrator, stated that if a resident had a guardianship, the facility would ask for documentation and it would be uploaded into the resident's EHR. Staff A stated 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.

Based on interview and record review, the facility failed to issue Notification of Medicare Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 1 of 3 residents (Resident 56), reviewed for beneficiary notification. This failure placed the resident and/or their representative at risk for not being fully informed and losing their right to an appeals process. Findings included . Review of the facility's policy titled, NOMNC Policy, revised on 09/12/2024, showed that A NOMNC will be issued at least 2 days, but not greater than 4 days, prior to the last covered day, to beneficiaries where it has been determined that Medicare A, B, or C covered services are no longer required. Review of Resident 56's NOMNC showed a last day of Medicare A coverage of 04/11/2025 and signed on 04/10/2025, one day before the end of Medicare A coverage. In an interview and joint record review on 05/16/2025 at 3:23 PM, Staff G,…

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 non-pharmacological interventions were in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 2 of 5 residents (Residents 64 & 57), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, adverse side effects, and a diminished quality of life. Findings included . Review of the facility policy titled, Psychotropic Medication Use, revised in July 2022, showed, A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior . non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. RESIDENT 64 Review of a face sheet printed on 05/13/2025 showed Resident 64 admitted to the facility on [DATE] with diagnosis…

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 a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 2 residents (Resident 2), reviewed for SCSA. This failure placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) program or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. The RAI manual further showed that the assessment should be completed…

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 coordinate the Preadmission Screen and Resident Review (PASARR) for Level II services (a process to determine what mental health services residents required after a Level I PASARR determined mental health services were necessary) for 1 of 2 residents (Resident 26), reviewed for PASARR. This failure placed the resident at risk of not receiving the necessary mental health services and a diminished quality of life. Findings included . Review of the facility's policy titled, PASRR, revised in July 2024, showed, Social services will review the completed PASRR [Level] II screening for any recommendations and will ensure that the patient [resident] receives the necessary services and that interventions are care planned . Care Planning for Level II PASRR Residents who have screened positive for Level II during the PASRR evaluation are required to have this reflected clearly in the care plan, and any recommendations made by the evaluator are to be included as…

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 Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 1 of 6 residents (Resident 36), reviewed for PASARR screening. In addition, the facility failed to complete Level I PASARR screening form for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 2 residents (Resident 57). These failures placed the residents at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities. Findings included . Review of the facility's policy titled, PASRR Policy, revised in July 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 observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for 2 of 4 residents (Residents 51 & 39), reviewed for quality of care. The failure to consistently conduct skin evaluations to include care planning, monitoring and necessary treatment for Resident 51, and the failure to consistently monitor and manage constipation (passing fewer than three stools a week or having a difficult time passing stool) for Resident 39, placed the residents and other residents at risk for unmet care needs, pain/discomfort, and related complications. Findings included . Review of the facility's policy titled, Wound Management Guidelines, revised on 03/31/2025, showed that skin checks were completed by the Licensed nurse weekly . CNA [Certified Nursing Assistant/NAC [Nursing assistant Certified]/Shower aides will report any alterations in skin identified during routine care .If a Resident is identified to have a new skin alteration 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 podiatry (the treatment of feet and their ailments) care and services were provided for 1 of 3 residents (Resident 10), reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life. Findings included . Review of the facility's policy titled, Foot Care, revised in October 2022, showed, Residents are provided with foot care and treatment in accordance with professional standards of practice . Residents are assisted in making appointments and with transportation to and from specialists (podiatrist) . Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes. Review of Resident 10's quarterly Minimum Data Set (MDS - an assessment tool) dated 04/22/2025, showed Resident 10 was cognitively intact and required substantial/maximal assistance (helper does more…

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 services were consistently provided to increase and/or to prevent decrease Range of Motion (ROM) for 2 of 3 residents (Residents 32 & 34), reviewed for restorative services. This failure placed the residents at risk for a decline in ROM, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Restorative Services, revised on 11/11/2005, showed, It is the policy of the facility to provide its residents the restorative services in an effort to maintain the residents highest level of self-care and independence, physically and psychosocially. RESIDENT 32 Review of the annual Minimum Data Set (MDS-an assessment tool), dated 04/05/2025, showed Resident 32 admitted to the facility on [DATE] with diagnosis that included cerebral palsy (a group of conditions that affect movement and posture). It further showed that Resident 32 had ROM impairment in their upper and lower extremities.…

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 residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 8 residents (Residents 4 & 39), reviewed for catheter care. The failure to empty urinary catheter bag and/or ensure other urinary catheter care were provided placed the residents at risk for infections, related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, [Urinary] Catheter Care, revised in August 2022, showed that the purpose of this procedure is to prevent urinary catheter-associated complications, including bladder infections. The document further showed that catheter tubing and drainage bag (collects urine from the catheter) were to be kept off the floor. RESIDENT 4 Review of Resident 4's admission minimum data set (an assessment tool) dated 02/03/2025, showed Resident 4 had a urinary catheter. Review of a provider note date 04/25/2025, showed that Resident 4 had informed, [that] sometimes her…

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

Based on observation, interview, and record review, the facility failed to ensure resident who require ostomy (a surgical procedure creating an opening in the body for the discharge of body waste into a collection bag) care received services consistent with professional standards for 1 of 1 resident (Resident 17), reviewed for ostomy care. This failure placed the resident at risk for unmet care needs, skin breakdown, related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Evaluation Guidelines for Managing Ostomy Care, revised in October 2015, showed Task completed should be documented via the Treatment Administration Record (TAR) .A physician's order should be obtained to match the required task(s) being performed. Review of the comprehensive care plan printed 05/13/2025 showed Resident 17 had a colostomy (type of ostomy). Review of Resident 17's physician orders printed on 05/13/2025 showed no orders related to colostomy. Review of Resident 17's Medication Administration Record (MAR) and/or TAR printed on 05/13/2025…

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 interview and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received trauma informed care, trigger assessment, and trauma-informed care assessment in accordance with professional standards of practice for 1 of 1 resident (Resident 48), reviewed for mood/behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a diminished quality of life. Findings included . Review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revised in August 2022, showed that it was the policy of the facility to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers (cause [an event or situation] to happen or exist)…

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 report an allegation of sexual abuse for 1 of 3 residents (Resident 1), reviewed for abuse reporting. The facility's failure to report an allegation of sexual abuse to the state agency and to law enforcement placed Resident 1 and other residents at risk for repeated incidents and unidentified abuse. Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, Abuse-Sexual, means any form of non-consensual conduct, including but not limited to, unwanted or inappropriate touching. It further showed that sexual contact may include interactions that do not involve touching including, but not limited to, sending sexually explicit messages, cueing, or encouraging a resident to perform sexual acts. Review of the facility's Abuse Policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated September 2022, showed mandated (required) reporters are to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of sexual abuse was investigated timely for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and a diminished quality of life. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, Abuse-Sexual, means any form of non-consensual conduct, including but not limited to, unwanted or inappropriate touching. It further showed that sexual contact may include interactions that do not involve touching including, but not limited to, sending sexually explicit messages, cueing, or encouraging a resident to perform sexual acts. Review of the facility's Abuse Policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated September 2022, showed, as soon as a report of an alleged or suspected abuse/neglect is received, the investigation shall begin to rule out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier Precautions (EBP- precautions to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) signage was in place and/or use of appropriate Personal Protective Equipment (PPE-gown) were followed during medication administration for 1 of 2 residents (Resident 1), reviewed for infection control. This failure placed the residents, staff, and visitors at an increased risk of infection and related complications. Findings included . Review of the facility's policy titled, Infection Control, revised in July 2002, showed that the facility's infection control policies and procedures are to establish guidelines to provide a safe and sanitary environment while preventing the development and transmission of disease and infection. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/21/2024, showed that PPE for EBP were necessary when…

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 primary care physician was notified when medications were not administered for 1 of 3 residents (Resident 1) reviewed for medications. The failure to notify the primary care physician when the medication (Levothyroxine) used to treat an underactive thyroid gland (a gland in the neck that affects heart rate, mood, and energy levels) and a medication (Trospium) used to treat an overactive bladder was not administered placed Resident 1 at risk for a decline in medical condition, skin impairments, and a diminished quality of life. Findings included . A review of the admission Minimum Data Set (MDS-an assessment tool) dated 07/15/2024, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis list that included a thyroid disorder. The MDS also showed the resident had intact thinking and had a loss of bladder control. Interview on 08/06/2024 at 3:03 PM, Resident 1 stated, I missed some days of my thyroid medication 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 interview and record review, the facility failed to ensure that 1 of 3 residents (Resident 1) was free from a significant medication error. The failure to administer a medication (Levothyroxine) used to treat an underactive thyroid gland (a gland in the neck that affects heart rate, mood, and energy levels) and a medication (Trospium) used to treat an overactive bladder placed Resident 1 at risk for a decline in medical condition, skin impairments, and a diminished quality of life. Findings included . A review of the admission Minimum Data Set (MDS-an assessment tool) dated 07/15/2024, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis list that included a thyroid disorder. The MDS also showed the resident had intact thinking and had a loss of bladder control. Interview on 08/06/2024 at 3:03 PM, Resident 1 stated, I missed some days of my thyroid medication and the medication I take to control my bladder. I am afraid my heart will start to beat too fast if I don't get my thyroid…

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 baseline care plans were developed within 48 hours of admission to ensure continuity of care and failed to ensure a summary or copy of the baseline care plan were provided to the residents and/or their representatives for 3 of 4 residents (Residents 1, 3 & 4), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Baseline Care Plan, revised in March 2022, showed that a baseline plan or care to meet resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The policy further showed that the baseline care plan includes instructions needed to effective, person-centered care of the resident that meet professional standards of quality care. RESIDENT 1 Resident 1 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS - an assessment tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary assistance for shower/bathing for 2 of 5 residents (Residents 1 & 2), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for unmet care needs, poor hygiene, skin impairment, and a diminished quality of life. Findings included . RESIDENT 1 Resident 1 admitted to the facility on [DATE]. Review of Resident 1 admission Minimum Data Set (MDS - an assessment tool) dated 06/17/2024, showed Resident 1 required total assist with shower/bathing. Further review of the MDS showed Resident 1 was cognitively intact. Review of the undated document titled, Shower Schedule Wing 3, showed room [ROOM NUMBER]-2 (Resident 1's room) was scheduled for shower/bathing on Tuesdays and Fridays. Review of the June 2024 Documentation Survey Report, showed Resident 1 did not receive a shower/bathing on 06/18/2024 (Tuesday) and on 06/21/2024 (Friday). Further review of the document did not show Resident 1 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 interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency within the required timeframe for 1 of 1 resident (Resident 1), reviewed for abuse allegation. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, showed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). The policy further showed, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Resident 1 admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegation of abuse was thoroughly investigated and/or completed/documented on the incident report log within five days for 1 of 1 resident (Resident 1), reviewed for abuse investigation. This failure placed the resident at risk for unidentified abuse and a diminished quality of life. Findings included . Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, showed that all allegations are thoroughly investigated. The policy further showed, The individual conducting the investigation as a minimum interviews staff members (on all shifts) who had contact with the resident during the period of alleged incident, reviews all events leading up to the alleged incident and documents the investigation completely and thoroughly. Upon conclusion of the investigation, the investigator records the findings of the investigation. Resident 1 admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 13 residents (Residents 4, 49, 53 & 45), reviewed for care plan revision. The failure to revise care plans for bed placed against the wall, refusal of showers, discharge planning, and involve resident in their care plan meetings, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person - Centered, revised in March 2022, showed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The policy showed that the interdisciplinary team reviews and updates care plans when there has been a significant change in the resident's condition, when the desired outcome is not met, when resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly…

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 clarify a physician's order for 1 of 8 residents (Resident 20) and failed to ensure staff documented residents' medications in accordance with professional standards for 5 of 8 residents (Residents 5, 20, 9, 361 & 52), reviewed for medication administration. This failure placed the residents at risk for medication errors and negative outcomes. Findings included . Review of the facility's policy titled, Administering Oral Medications, revised in October 2010, showed their policy provided guidelines for the safe administration of oral medications. The policy further showed to check the label on the medication and confirm the medication name and dose with the Medication Administration Record (MAR). Review of the facility's policy titled, Documentation of Medication Administration, revised in November 2022, showed that administration of medication is documented immediately after it is given. A MAR is used to document all medications…

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

Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 2 of 6 days reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility. Findings included . Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2022, showed that within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nurses directly responsible for resident care is posted in a prominent location and in a clear and readable format. The information recorded should include the actual time worked during that shift for each category and type of nursing staff and total number of licensed and non-licensed nursing staff working for the posted shift. 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 observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 3 of 4 freezers (Kitchen Freezer, Kitchen Walk-In Freezer and Downstairs Storage Freezer), 1 of 2 refrigerators (Cellarium Refrigerator), and 1 of 1 seasoning shelf (Kitchen Shelf) reviewed for food services. The failure to date and discard expired food items and/or before use by date, placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Safety and Sanitation, revised on 01/2024, showed that opened food products will be used or discarded by timeframes consistent with federal guidelines and state food rules/codes. The policy showed that if use-by guidelines exceed the printed use by/expiration date from the manufacturer, the food item/s are to be used or discarded by the printed manufacturer use by/expiration date. The policy further…

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 have a comprehensive water management program that assessed, measured, and/or monitored potential risk for exposure to Legionnaire's disease (Legionella - a potentially dangerous bacteria that grows in water, which could cause a serious lung infection) or other waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease). In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during resident care for 2 of 4 staff (Staff R & S), failed to appropriately disinfect medical equipment for 3 of 4 staff (Staff S, T & J), and failed to do hand hygiene during dining meal observations for 2 of 3 staff (Staff J & M), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . WATER MANAGEMENT PROGRAM Review of the facility's policy titled,…

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 advance directives (a written instruction, such as a living will or durable power of attorney for health care) were obtained from the residents and/or their representatives and ensure a copy was readily available in the medical records for 2 of 4 residents (Residents 45 & 38), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive care according to their choice. Findings included . Review of the facility's policy titled, Advance Directives, revised in September 2022, showed, prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The policy showed that if the resident or representative indicates that he or she has not established advance directives, the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - a required form that outlined the transfer of financial liability from the nursing facility to the Medicare [government health insurance program] beneficiary) for 3 of 5 residents (Residents 160, 30 & 161), reviewed for liability notices, who remained in the facility after their Medicare Part A skilled nursing and rehabilitation services ended. This failure placed the residents and/or their representatives at risk for not having adequate information to make financial decisions related to continued stay in the facility. Findings included . Review of the facility's policy titled, SNF ABN, revised on 09/01/2023, showed, a SNF ABN shall be issued to qualified beneficiaries following a skilled stay when the beneficiary chooses to remain in the facility. The SNF ABN is a liability notice, and it provides information to the beneficiary so that an informed decision may be made…

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 a clean, comfortable, and homelike environment for 1 of 1 room (room [ROOM NUMBER]), reviewed for environment. The failure to prevent excessive odor placed the resident at risk for feeling unclean, undignified, and a diminished self-worth. Findings included . Resident 47 admitted to the facility on [DATE]. Review of the Electronic Health Record showed Resident 47 had been in room [ROOM NUMBER] since 10/04/2023. Review of the quarterly Minimum Data Set (an assessment tool) dated 01/26/2024, showed Resident 47 was cognitively intact. On 03/12/2024 at 8:49 AM, room [ROOM NUMBER] had a strong smell of urine. The strong urine odor continued through 03/13/2024 at 2:15 PM, on 03/14/2024 at 10:00 AM, on 03/14/2024 at 10:58 AM, and on 03/15/2024 at 12:23 PM. Observation and interview on 03/13/2024 at 2:15 PM, showed Resident 47 had a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) bag full of urine.…

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 identify, initiate, thoroughly investigate, and promptly resolve a grievance for 1 of 2 residents (Resident 15), reviewed for grievances. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Grievance, revised in May 2000, showed, the nursing facility will listen to and act promptly upon grievances. The policy showed that Formal grievances are to be made in writing and the resident fills out the top portion of the grievance communication form and staff will assist if requested. The appropriate department supervisor will take immediate action toward resolution of the concern and will record the resolution on the bottom section of the form. The policy further showed that resolved grievances will be maintained .for one year. Resident 15 admitted to the facility on [DATE]. Review of Resident 15's Inventory of Personal Effects document 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 accurately assess 1 of 6 residents (Resident 49), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, coding instructions to code all high risk drug class medications according to their pharmacological (drug's uses, effects, and modes of actions) classification and not how they are being used. It also showed to check if the resident is taking any medication by pharmacological classification during the 7-day observation period. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a baseline care plan for 1 of 4 residents (Resident 23), reviewed for baseline care plans. The failure to implement the baseline care plan for nutritional risk placed the resident at risk for health complications, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans-Baseline, revised in March 2022, showed, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care. Review of the facility's policy titled, Dysphagia [difficulty swallowing foods or liquids] Diets and Aspiration [occurs when food or liquid is breathed into the airways or lungs] Precautions, dated October 2021, showed that Dysphagia diets and aspiration precautions will be individualized with modifications made by the Speech Language Pathologist [SLP - treat many types of communication and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident 23), reviewed for accidents. The failure to provide necessary supervision placed the resident at risk for accidents, injury, and other negative outcomes. Findings included . Review of the facility's policy titled, Assistive Devices and Equipment, revised in January 2020, showed, The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment . and .the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. The policy further showed that staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise as needed. Resident 23 readmitted to the facility on [DATE] with diagnosis that included cerebral palsy (a group of disorders that affect a person's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and monitor a resident weight for 1 of 2 residents (Resident 23), reviewed for nutrition. This failure placed the resident at risk for unrecognized weight loss, nutrition-related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Nutrition and Hydration: Weight Systems and Assessment, dated October 2023, showed, The purpose of this standard is to ensure baseline weights are obtained; significant weight variance; insidious weight loss; and weight trends are identified, assessed and monitored. The policy further showed, Nursing will obtain patient [resident] weight on the first day of admission, maximum of 24 hours, for admission/readmission and weekly for four weeks thereafter. This weight will be entered into the Electronic Medical Record as the baseline weight. Resident 23 readmitted to the facility on [DATE]. Review of Resident 23's nutrition care plan revised on 03/11/2024, showed…

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 respiratory equipment to include covering the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use, labeling the tubing, and ensure oxygen therapy was given according to standards of practice for 2 of 2 residents (Residents 23 & 26), reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included . RESIDENT 23 Resident 23 readmitted to the facility on [DATE] with a diagnosis that included acute and chronic respiratory failure (a condition that happens when lungs cannot get enough oxygen into the blood). Review of Resident 23's March 2024 Treatment Administration Record showed CPAP on at HS [at bedtime] and when sleeping, started on 03/12/2024. Review of Resident 23's respiratory therapy care plan revised 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 provide the required Registered Nurse (RN) coverage for 1 of 30 days (02/25/2024), reviewed for staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Staff, Sufficient and Competent Nursing, revised in August 2022, showed, A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. Review of the facility's form titled, Daily Nursing Staff, dated 02/25/2024, showed no RN coverage for all shifts. Review of the daily nurse schedule for 02/25/2024 showed that Staff D, Registered Nurse, worked as the Resident Care Manager for five and one-half hours (not the required eight hours). No other RNs worked on that day. In an interview and joint record review on 03/19/2024 at 12:59 PM with Staff B, Director of Nursing, stated that we have a lot [of RNs] on staff when asked what the facility did if there was not an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (%). The failure to properly administer 9 of 53 medications for 2 of 8 residents (Residents 20 & 52), observed during medication pass resulted in a medication error rate of 16.98%. This failure placed the residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications and possible adverse effects. Findings included . Review of the facility's policy titled, Administering Oral Medications, revised in October 2010, showed their policy provided guidelines for the safe administration of oral medications. It further showed to check the label on the medication, confirm the medication name and dose with the Medication Administration Record (MAR). Review of the facility's policy titled, Administering Medications through an Enteral Tube [medical device used to provide nutrition directly into the stomach or small…

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 appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 medication carts (Wing 1 Medication Cart), reviewed for medication storage. This failure placed the resident at risk for receiving compromised and ineffective medications. Findings included . Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed that multi-dose (more than one dose) vials (small glass container for holding liquid medicine) that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Joint observation and interview on 03/14/2024 at 11:36 AM with Staff K, Licensed Practical Nurse, showed the Wing 1 Medication Cart had one opened and undated multi-dose vial of Novolin R insulin (a type of insulin - medication that works by lowering levels of sugar in the blood) for Resident 34. Staff K stated Resident 34's insulin vial should have been…

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 1 of 2 residents (Resident 26) reviewed for dental services was provided timely referral to a dentist and reimbursement for missing dentures. In addition, the facility failed to have a policy that identified when the loss of dentures was the facility's responsibility. These failures placed the resident at risk for difficulty chewing, oral pain, decreased self-image, financial burden, and diminished quality of life. Findings included . Review of the facility's policy titled, Lost Item Policy, revised in September 2004, showed, It is the policy of this facility to protect residents' items from theft or loss to the extent possible. Every effort will be made to insure against theft or loss, to recapture lost items, or to make restitution should a lost item not be recovered. Resident 26 admitted to the facility on [DATE]. Review of a facility form titled, Inventory of Personal Effects, dated 12/09/2021, showed Resident 26's upper partial dentures 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 interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a manner that the resident and/or representative understood for 1 of 3 residents (Resident 52), reviewed for arbitration agreement. This failure placed the resident at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life. Findings included . Review of the facility's policy titled, Arbitration Agreement, dated 01/04/2021, showed the admission coordinator would review the arbitration agreement with the admission and obtain signature for agreement or decline. Review of a facility document titled, Patient [resident] and Facility Arbitration Agreement, showed that Resident 52's Representative (RR1) signed the arbitration agreement on 11/28/2023. On 03/18/2024 at 12:31 PM, RR1, stated they did not remember signing an arbitration agreement. RR1 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and/or their representatives received information on the current recommendations from the Center for Disease and Control (CDC) Prevention for 2 of 8 residents (Residents 52 & 4) related to pneumococcal vaccinations (vaccines used to prevent pneumonia [lung infection]). This failure placed the residents at risk for acquiring, transmitting and/or experience potentially avoidable complications from pneumonia. Findings included . Review of the facility's policy titled, Pneumococcal Vaccine, revised in March 2022, showed All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections . Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission . The policy showed that before the resident received the vaccine the resident or legal representative would receive…

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 allegation of abuse was thoroughly investigated and/or logged and completed timely within five days for 3 of 3 residents (Residents 3, 4 & 5), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2022, showed that any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. INCIDENT INVESTIGATION RESIDENT 3 Resident 3 readmitted to the facility on [DATE]. Review of the facility's investigation summary report titled, Alleged Abuse, dated 01/22/2024, showed Staff B, Certified Nursing Assistant, made Resident 3 cry and made them feel bad for soiling their bed. Further review of the investigation showed Staff B…

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 abuse allegation was thoroughly investigated for 1 of 2 residents (Resident 1) reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unrecognized abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2022, showed that all allegations are thoroughly investigated. The individual conducting the investigation as a minimum interviews staff members (on all shifts) who had contact with the resident during the period of the alleged incident, interviews other residents to whom the accused employee provides care or services, documents the investigation completely and thoroughly. Upon conclusion of the investigation, the investigator records the findings of the investigation. Resident 1 admitted to the facility on [DATE]. Review of the quarterly Minimum Data…

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

Based on observation, interview, and record review, the facility failed to ensure the menu met the nutritional needs of residents in accordance with the established national guidelines for well-balanced diet/menu. This failure placed the residents at risk for not having their food choices honored, unmet nutritional needs, and a diminished quality of life. Findings included . Review of the undated facility's policy titled, Menu Planning indicated the Nutritional needs of individuals [residents] will be provided in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences . through nourishing, well-balanced diets, unless contraindicated by medical needs . Menus are written using an accepted, standard meal planning guide, such as the USDA [United States Department of Agriculture] MyPyramid. Review of the USDA Dietary Guidelines for Americans 2020-2025 [This was retrieved on 12/25/2022] indicated, Calorie Level: 1800: Vegetables: 2 1/2 cups/day; Fruits: 1 1/2 cups/day; Dairy: 3 cups/day; Protein…

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

Based on interview and record review, the facility failed to ensure annual comprehensive Minimum Data Set (MDS) assessments were completely timely as required for 5 of 21 residents (Residents 3, 22, 30, 10 & 35) reviewed for comprehensive assessments. The facility's failure to conduct annual comprehensive assessments placed the residents at risk of unidentified physical, psychological, functional changes, other unmet care needs and a diminished quality of life. Findings included . Review of the Resident Assessment Instrument (RAI) Manual, October 2019 edition, revealed the facility is to conduct a comprehensive assessment no more than 366 days from the previous comprehensive assessment. RESIDENT 3 Review of the Electronic Medical Record (EMR) revealed an admission date of 08/13/2013 for Resident 3. Review of the MDS list of activity for Resident 3, revealed an annual comprehensive assessment was last completed on 12/20/2021, more than one year ago. RESIDENT 22 Review of the EMR revealed an admission date of 11/14/2021 for Resident 22. Review of the MDS list of activity 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 staff interview and record review, facility failed to ensure Minimum Data Set (MDS) assessments were conducted timely for 11 of 21 residents (Residents 27, 66, 13, 39, 24, 46, 36, 14, 23, 12 and 37) reviewed for Quarterly MDS Assessments. This failure placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life. Findings included . Review of the ''Resident Assessment Instrument [RAI] Manual,'' October 2019 edition, used by the facility to direct the type of assessment needed and instructions of how to complete the assessment, indicated that a quarterly assessment was to be completed at least every 92 days when a comprehensive assessment was not required. RESIDENT 27 Review of Resident 27's Electronic Medical Record (EMR), under the Census tab revealed an admission date of 04/05/2021. Review of the MDS tab, revealed Resident 27's last assessment was a comprehensive MDS assessment completed on 07/05/2022. The facility failed to perform a quarterly assessment within 92 days. RESIDENT 66 Review of Resident 66's EMR revealed an 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 the food was palatable, attractive, and at a safe and appetizing temperature for 6 of 6 residents (Residents 14, 42, 374, 35, 40 and 15) reviewed for palatability. This failure placed the residents at risk for weight change, less than adequate nutritional intake, and dissatisfaction with meals. Findings included . Review of the undated facility's policy titled, Food Temperatures indicated All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F [Fahrenheit] . Temperatures should be taken periodically to ensure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the portioning, transporting and serving process until received by the resident. Review of the undated facility's policy titled, Dietary Services- Food and Drink indicated The facility will provide to each resident: Food prepared by methods that conserve nutritive value, flavor, and appearance; Food and drink that is palatable, attractive, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a water management program to reduce the potential for exposure to opportunistic waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease) including Legionnaire's disease, a potentially dangerous bacteria that grows in water, which could cause a serious lung infection (Pneumonia). This failure created a potential risk for the facility residents to be exposed to Legionella, other opportunistic water-borne pathogens, and related complications. Findings included . Review of the website for American Society of Heating, Refrigerating and Air-Conditioning Engineers titled, Risk Management for Legionellosis, dated 10/15, indicated . The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors . Health-care facility with patient stays over 24 hours .…

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

Based on observation, interview, and record review, the facility failed to provide hot water to the sink in the room of 1 of 47 residents (Resident 42) reviewed for accommodation of needs. The failure to have hot water and weak water pressure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . The facility did not have a policy to address water temperatures in the resident rooms. Review of Resident 42's Face Sheet revealed Resident 42 was admitted to the facility originally on 09/10/2022. The resident's diagnoses included encounter for orthopedic aftercare following surgical amputation. Review of Resident 42's admission Minimum Data Set with an assessment reference date of 09/17/2022 revealed Resident 42 had a Brief Interview for Mental Status score of 15 out of 15 indicating the resident was cognitively intact. Observation on 12/19/2022 at 10:07 AM, revealed Resident 42 was seated on his bed in his room. During this meeting, Resident 42 said the hot water in his room never got hot and stated, It is not hot enough to wash your face…

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 report an allegation of neglect or mistreatment that did not result in bodily harm, no later than 24 hours after the allegation was reported for 1 of 1 resident (Resident 66) reviewed for abuse and neglect. This failure placed the resident at risk for neglect, mistreatment, and unreported allegations. Findings included . Review of the facility policy titled, ''Abuse and Neglect Policy and Procedure,'' dated 07/05/2022, showed, 5. This facility will report all alleged violations to the State Agency and to other agencies as required.'' Review of the electronic medical record (EMR) for Resident 66 under the Census tab, revealed an admission date of 08/09/2022, and a diagnosis that included anxiety. Review of the EMR under the Care Plan tab revealed an undated ''Behavior Care Plan for Aggressive Behavior (Verbal/Physical) Template,'' which indicated Resident 66 was irritable, verbally threatening and makes false accusations related to medical issues and psychological issues ''(such as dementia [memory loss], depression 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 interview and record review, the facility failed to investigate an allegation of neglect or mistreatment for 1 of 1 resident (Resident 66) reviewed for abuse and neglect. This failure placed the resident at risk for unrecognized abuse or neglect, and a diminished quality of life. Findings included . Review of the facility policy titled, ''Abuse and Neglect Policy and Procedure'' dated 07/05/2022, stated, ''All resident events reported . will be investigated to determine if abuse has occurred .'' The Procedure section ''3. Any alleged . abuse will be reported to the Administrator and Director of Nursing as soon as possible .'' The Procedure continues ''4. All investigations will include a statement form staff involved as well as from the resident.'' The policy directs that the residents will be protected during the investigation. Review of Resident 66's the Electronic Medical Record, under the census tab revealed an admission date of 08/09/2022, and a diagnosis that included anxiety. Review of the Care Plan revealed an undated ''Behavior Care Plan for Aggressive Behavior…

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 review, the facility failed to consistently complete and/or transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 3 of 21 residents (Residents 27, 12 & 10) reviewed for timeliness in submitting Minimum Data Set (MDS) assessments and/or completing and transmitting death in facility tracking record. These failures placed the residents at risk for inaccurate/incomplete assessments, unmet care needs, and a diminished quality of life. Findings included . Review of the ''Resident Assessment Instrument [RAI] Manual,'' October 2019 edition, used by the facility to direct the type of assessment needed and instructions of how to complete the assessment, indicated on page 2-32 revealed, The MDS must be transmitted (submitted and accepted into the QIES [Quality Improvement and Evaluation System] ASAP [Assessment Submission and Processing] system) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). Page 2-36 of the RAI Manual also showed, Death 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 develop and implement a comprehensive care plan for 1 of 1 resident (Resident 3) with a tracheostomy stoma (an artificial opening in the neck for breathing and respiratory secretions). This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of Resident 3's Electronic Medical Record under the Census tab revealed Resident 3's admission date was 08/13/2013. Resident 3's diagnoses included diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), sleep apnea (potentially serious sleep disorder in which breathing repeatedly stops and starts), and a tracheostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed tracheostomy was coded/marked on the MDS. Review of the care plan revealed no goals or interventions for the care of Resident 3's tracheostomy stoma. Review of Orders revealed there were no orders for 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 maintain acceptable parameters of nutritional status, such as usual body weight, for 1 of 6 residents (Resident 15) reviewed for nutritional status. The facility's failure to ensure Resident 15 received the appropriate diet texture and assess for needed changes in interventions resulted in significant weight loss. Findings included . Review of the facility's policy titled, Nutrition and Hydration Monitoring updated on 05/17/2021 indicated the Facility will attempt non-drug interventions to address weight loss which may include but not limited to: a. Enhanced calorie intake based on RD [Registered Dietitian] recommendation b. Assess and modify diet and assistance received c. Assess for any special utensils, texture modification, cut-up, feeding assistance d. Offer pudding, cottage cheese, ice cream, milk shakes per RD recommendations . All nutritionally at-risk resident weights will be tracked and monitored weekly, until weight is stable,…

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 risks and benefits of side rails were completed and that the side rails were regularly evaluated for safety for 1 of 1 resident (Resident 11) who had two, one-fourth siderails on their bed. This failure placed the resident at risk for entrapment and/or injury. Finding included . Observation and interview on 12/20/2022 at 8:41 AM, Resident 11 was in bed with 2 upper 1/4 bed rails in the raised position. Interview revealed Resident 11 was unable to reposition with the side rails and required assistance from the staff. Review of Resident 11's significant change Minimum Data Set assessment dated [DATE] revealed Resident 11 required extensive assistance from two staff for bed mobility. Review of the Electronic Medical Record revealed no evidence of a side rail assessment for Resident 11 that indicated Resident 11 used the rails as an enabler to assist in repositioning. An interview on 12/22/2022 at 3:37 PM, the Administrator (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 observation, interview, and record review, the facility failed to provide behavioral health services for 1 of 47 residents (Resident 41) reviewed for mental health provision and services. This failure placed the residents at risk for unmet psycho-social needs and diminished quality of life. Findings included . Review of the facility policy titled, Behavioral Health Services, updated on 07/07/2022, revealed Policy statement: Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes but is not limited to, the prevention and treatment of mental and substance use disorders. Review of Resident 41's Electronic Medical Record (EMR), under Face Sheet revealed that Resident 41 was admitted to the facility originally on 10/20/2022 with diagnosis that included depression. Review 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 ensure proper diet texture consistency for 1 of 1 resident (Resident 374) reviewed for nutrition and specialty diet. This failure placed the resident at risk for nutritional imbalance, weight changes and a diminished quality of life. Findings included . Review of the undated facility's diet manual titled, Dysphagia [difficulty swallowing] Mechanically Altered (Level 2) Diet indicated Meat or meat alternative: Ground as tolerated, moistened with sauce or gravy; Vegetables: Cooked, tender, chopped, or shredded; Grains: Pureed or slurried and gelled; well cooked noodles, soft pancakes well moistened with syrup or sauce. Review of the undated facility policy titled, Dietary Services-Food and Drink indicated The facility will provide to each resident: Food prepared in a form designed to meet individual needs. Review of the undated facility policy titled, Menu Planning indicated Regular and therapeutic menus are written by the facility's food and nutritional professional in accordance with the facility's approved…

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 ready-to-eat food was handled appropriately in accordance with professional standards for food service safety for 1 of 1 dining room. This failure placed the resident at risk for food-borne illness. Findings included . Review of the undated facility's policy titled, General Food Preparation and Handling indicated Bare hands should never touch raw food directly . Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Observation in the dining room on 12/20/2022 at 7:47 AM, the Nurse Aide (Staff I) was observed putting butter and jelly on Resident 5's bread. Staff I picked up the resident's bread with her bare hands. An interview on 12/20/2022 at 8:40 AM, Staff I acknowledged she handled the resident's bread with her bare hands. She said she had been previously educated on the proper handling of ready-to-eat food. An interview on 12/22/2022 at 3:32 PM, the Director of Nursing (Staff B) confirmed Staff I…

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.