Ballard Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs were properly labeled and stored in accordance with current accepted professional standards for 3 of 3 medication carts (Medication Cart 3, Medication Cart 4 & Medication Cart 2), and for 1 of 2 medication rooms (Medication room [ROOM NUMBER]), reviewed for medication storage and labeling. These failures placed the residents at risk of receiving compromised and ineffective medications.Findings included .Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.Multi-dose vials that have been opened or accessed (e.g. [example] needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.MEDICATION CART 3 A joint observation and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. In addition, the facility failed to ensure hand hygiene was performed after removal of Personal Protective Equipment (PPE - gloves and gown), disinfect shared medical equipment after resident use, ensure proper PPE and/or Enhanced Barrier Precautions [EBP-specialized infection control measures used to prevent the spread of specific infections) were followed for 3 of 8 staff (Staff P, Staff L & Staff M), reviewed for infection control. These failures placed residents, visitors, and staff at an increased risk for infection and related complications. Findings included. Review of the facility's policy titled, Infection Prevention and Control Program, dated 09/18/2023, showed, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident was evaluated, and a physician order was obtained for safe administration of medication for 1 of 1 resident (Resident 25), reviewed for self-administration of medication. This failure placed the resident at risk for inaccurate and unsafe medication administration, adverse side effects, and medical complications.Findings included.Review of the facility's policy titled, Self-Administration of Medications, revised in February 2021, showed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy showed that if the resident had been determined to be not safe to self-administer medication, the nursing staff would administer the resident's medications. The policy further showed, Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transmit the resident Minimum Data Set (MDS-an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 1 of 32 residents (Resident 94), reviewed for resident assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument [RAI-instructional guidelines for MDS completion] 3.0 User's Manual Version 1.20.1, revised in October 2025, showed that a discharge (non-comprehensive) MDS must be completed no later than 14 days after the Assessment Reference Date (ARD-look back period), and it must be submitted/transmitted within 14 days of the MDS completion date to the database as required.Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised in October 2023, showed, Our facility will conduct and submit resident assessments in accordance with current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Preadmission Screen and Resident Review (PASRR or PASARR) Level II (refers to the evaluation process conducted after a Level I screening indicates a possible serious mental illness or intellectual disability to ensure that individuals receive appropriate care and support based on their specific needs and conditions) was obtained for 2 of 10 residents (Residents 6 & 30), reviewed for PASRR coordination. This failure placed the residents at risk of not receiving the necessary behavioral health services and a diminished quality of life.Findings included .Review of the facility's policy titled, PASRR Completion, revised on 09/30/2024, showed, The Center will make sure that all admissions have the appropriate Patient [Preadmission] Screen and Resident Review (PASRR) completed. The facility will [follow] state-specific guidelines for completion.RESIDENT 6Review of an admission record printed on 04/08/2026 showed Resident 6 had diagnoses that included schizophrenia (a chronic mental disorder with symptoms such 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.

Based on interview and record review, the facility failed to ensure a new Level I Preadmission Screening and Resident Review (PASARR or PASRR-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) was completed for an exempted hospital discharge resident who remained in the facility for more than 30 days and/or a Level I PASARR was completed accurately for 2 of 10 residents (Residents 99 &19), reviewed for PASARR screening. These failures placed residents at risk of not receiving the appropriate care, limited access to necessary specialized services, and a diminished quality of life.Findings included. Review of the facility's policy titled, PASRR Completion Policy, revised on 09/30/2024, showed, The Center will make sure that all admissions have the appropriate Patient [Preadmission] Assessment and Resident Review (PASRR) completed. The policy further showed that the facility would follow state-specific guidelines…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the State Pre-admission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people [residents] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care) Coordinator and complete a new Level I PASARR after a significant change in status occurred for 1 of 1 resident (Resident 7), reviewed for PASARR. 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, PASRR Completion Policy, revised on 09/30/2024, showed that the facility would follow state-specific guidelines for completion. Review of the Level I PASRR form revised in June 2025 showed, In the event the resident experiences a significant change in condition.the NF [Nursing Facility] must complete a new PASRR Level 1 and make referrals to the appropriate entities. Review of the admission record printed 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 develop and/or implement a care plan for 2 of 26 residents (Residents 1 & 19), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for psychotropic (medications that change how the brain works to affect mood, thoughts, feelings, or behavior) and Post Traumatic Stress Disorder (PTSD - a mental health condition that can develop after a traumatic event) 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, dated 08/25/2021, showed, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. RESIDENT 1Review of the admission Minimum Date Set (MDS-an assessment tool) dated 02/09/2026 showed Resident 1 was receiving an antidepressant (a psychotropic drug that relieves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan was revised accurately to reflect changes related to use of hearing devices for 1 of 2 resident (Resident 66), reviewed for care planning. This failure placed resident at risk for unidentified and unmet care needs, and a diminished quality of life.:Findings included. Review of the facility's policy, titled, Care Plan Comprehensive, dated 08/25/2021, showed, Assessments of resident are ongoing, and care plans are reviewed and revised as information about the resident and the resident condition change. Review of the comprehensive care plan printed on 04/10/2026 showed Resident 66 had impaired communication as evidenced by hard of hearing. Further review of Resident 66's impaired communication care plan showed the following interventions that were created between 2018 to 2022 and did not show they were revised to reflect Resident 66's status:- Ensure batteries are working in pocket talker-[Resident 66] has bilateral hearing aids.-Plug in [Resident 66's] hearing aids every night-[Resident 66]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ongoing activities/programs for 1 of 1 resident (Resident 91), reviewed for activities. This failure placed the resident at risk for unmet leisure interests, poor psychosocial well-being, and a diminished quality of life.Findings included. Review of the facility's policy titled, Activity Programs, revised in June 2018, showed, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. The policy showed that activities were scheduled seven days a week.The policy further showed that all activities were documented in the resident's medical record.reflected the.choices and rights of the residents.hobbies, life experiences and personal preferences of the residents. Review of Resident 91's Recreation Comprehensive assessment dated [DATE] showed, While in the facility, resident states that it is important that [they have] the opportunity to engage in daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 coordination of care and communication with medical providers were consistently followed timely in accordance with professional standards of practice and ensure neurological/neuro assessments (used to establish a baseline or identify acute changes in condition) were consistently conducted following an unwitnessed fall for 1 of 1 resident (Resident 106), reviewed for change of condition. These failures placed residents at risk for potential harm, poor clinical outcomes, unmet care needs, and a diminished quality of life.Findings included.Review of the facility's undated policy titled, Transfer or Discharge, showed that when the facility transfers or discharges a resident, the basis for the transfer or discharge, date and time, mode of transportation, and a summary of the resident's overall medical, physical, and mental condition are documented in the medical record and appropriate information is communicated to the receiving health care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services in accordance with accepted professional standards of practice for 2 of 2 residents (Residents 71 & 25), reviewed for respiratory care. The failure to properly store the Bilevel Positive Airway Pressure (BiPAP - a noninvasive ventilator that helps people breathe easier by delivering pressurized air through a mask) mask and oxygen (O2) nasal cannula (flexible tube used to deliver O2) when not in use, ensure to label/date O2 tubing, and to change AIRVO 2 (a humidifier with an integrated flow generator that delivers warmed, humidified, high-flow air and/or oxygen) water bag, placed the residents at risk for unmet care needs, respiratory infections, and related complications.Findings included . Review of the undated facility's policy titled, CPAP [Continuous Positive Airway Pressure – a device that treats sleep apnea (disorder where breathing repeatedly stops and starts while sleeping)]/BiPAP Support and Cleaning,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consistently monitor weights before and after hemodialysis (a procedure that removes waste from the blood via a machine when the kidneys can no longer function properly) and include transportation information in the care plan per professional standards of practice for 1 of 3 residents (Resident 19), reviewed for dialysis. This failure placed the resident at risk for unmet care needs, related complications, and adverse outcomes.Findings included. Review of the facility's policy titled, Dialysis Care, dated 08/25/2021, showed, To provide dialysis care for residents in renal [kidney] failure and those residents who require ongoing dialysis treatments. The policy further showed that the facility would arrange transportation to and from the dialysis provider and that the resident's care plan will be updated as needed. Review of the admission record printed on 04/09/2026 showed Resident 19 was admitted to the facility on [DATE] with diagnoses that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform hand hygiene before putting on new gloves for 2 of 6 staff (Staff Z and Staff AA), reviewed for food services. This failure placed the residents at risk for food-borne illnesses (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 Preparation and Service, revised in November 2022, showed, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.Observation on 04/10/2026 at 12:29 PM showed Staff Z, Assistant Dietary Manager, cut up the baked fish with a knife while they held the baked fish in place with their other gloved hand. Staff Z proceeded to remove and discard their soiled gloves and then put on new gloves. Staff Z did not perform hand hygiene between glove change.Observation 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 ensure pneumococcal vaccine (used to prevent pneumonia [a lung infection]) was administered for 1 of 5 residents (Resident 19), reviewed for pneumococcal immunization. This failure placed the resident at risk for acquiring, transmitting, and/or experiencing potential complications from pneumococcal disease.Findings included. Review of the facility's policy titled, Pneumococcal Vaccine, revised in October 2023, showed that all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy further showed, Pneumococcal vaccines are administered to residents.per our facility's physician-approved pneumococcal vaccination protocol. Review of the Vaccine Informed Consent dated 10/02/2025 showed Resident 19 had signed to receive a pneumococcal vaccine. Review of Resident 19's Electronic Health Record (EHR-immunization record, progress/clinical notes and treatment record) did not show Resident 19 was administered their pneumococcal vaccine. In an interview and joint record 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 interview and record review, the facility failed to complete thorough and timely investigations for 3 of 5 residents (Residents 1, 3 & 4), reviewed for abuse/incident investigations. This failure placed the residents at risk for unidentified abuse, repeated incidents and a diminished quality of life.Findings included.Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2025, showed, The facility must have evidence that all alleged violations are thoroughly investigated. The guidelines showed the results of all investigations must be reported to the administrator or their designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.Review of the facility's Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, dated September 2022 showed all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to log an allegation of unprofessional conduct on the facility's reporting log for 1 of 5 residents (Resident 3), reviewed for incident investigations. This failure placed the residents at risk of unidentified abuse and a diminished quality of life. Findings included. Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed reporting guidelines for nursing homes for an allegation of staff to resident abuse indicated to log the allegation on the facility's reporting (Department of Social and Health Services) log within five days. Review of the quarterly Minimum Data Set assessment (a required assessment tool) dated 02/10/2026 showed the resident was readmitted to the facility on [DATE]. The MDS further showed Resident 3 did not have problems with their memory or thinking. Review of the facility's incident investigation form dated 02/19/2026 showed Resident 3 complained that a staff member [Staff C, Recreation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 5 residents (Residents 1, 2 and 3), reviewed for discharge care plans. The failure to develop a care plan to address necessary care and services for planned discharges placed the residents at risk for unmet care needs and a diminished quality of life. Findings included .Review of the facility Comprehensive Care Plan Policy dated 08/25/2021 showed a comprehensive care plan is developed within seven days of completion of the comprehensive assessment (MDS [Minimum Data Set- a required assessment]. The policy also showed the comprehensive care plan included the following, the resident's preference and potential for future discharge, a discharge plan that addresses the resident's discharge goal(s), the preparation of resident and/or resident representative to be an active partner and transition them to post-discharge care, and the reduction of factors leading to preventable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriate discharge instructions including a discharge summary or recapitulation of stay for 3 of 4 residents (Residents 2, 3 & 4), reviewed for discharge process. This failure placed the residents at risk for lack of knowledge regarding their medical status and medications at the time of discharge, a break in communication and continuity of care, unmet care needs and diminished quality of life. Findings included.Review of the facility's policy titled, Discharge Against Medical Advice [AMA], dated 03/22/2022, showed that AMA discharges will be processed in accordance with the resident's/representative's request to arrange for a safe appropriate discharge. Documentation will be completed as applicable.RESIDENT 2 Review of a face sheet showed Resident 2 admitted to the facility on [DATE] with diagnoses that included type II diabetes (a condition affecting a person's ability to produce a hormone to move sugar from food into the body's cells),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 verify and follow the code status (medical care elected by a person in the event their heart or breathing stops) for 1 of 3 residents (Resident 1), and failed to ensure licensed nursing staff had current cardiopulmonary resuscitation (CPR-an emergency procedure consisting of chest compressions combined with giving breaths of air) certification for 2 of 6 staff (Staff E & F), reviewed for CPR. The failure to follow advance directive (written document of a person's expressed emergency care) and timely CPR training for staff placed the residents at risk for unwanted CPR, avoidable trauma and negative health outcomes.Findings included.Review of the facility's undated policy titled, Advance Directive, showed that upon admission, staff will inform the resident of their right to execute an Advance Directive Form. It further showed that A copy of the Advance Directive is maintained as part of the resident's medical record.Review of the facility's undated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 of 3 residents (Resident 1 & Resident 2), reviewed for abuse reporting. The facility's failure to report an allegation of sexual abuse to law enforcement placed the 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, Abuse Investigating and Reporting, revised in July 2017, showed, all alleged violations involving abuse will be reported by the facility Administrator or his/her designee to the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective pest control system was in place for 2 of 3 residents (Residents 1 & 2), reviewed for pest control. This failure placed the residents at risk for unsafe living conditions, emotional distress and a diminished quality of life. Findings included . Review of the facility's Pest Control Policy, revised on May 2008, showed, Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. RESIDENT 1 Review of the Significant change in Status Minimum Data Set (MDS- an assessment tool) dated 12/31/2024 showed Resident 1 readmitted to the facility on [DATE] and required a foley catheter (a tube used to drain urine from the bladder) due to body paralysis from waist down. Review of a nursing progress note dated 02/03/2025 showed Resident 1 requested to go to the hospital on [DATE] for…

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

Based on interview and record review, the facility failed to timely initiate and/or investigate an allegation of neglect for 1 of 3 residents (Resident 1), reviewed for abuse/neglect investigation. This failure placed the resident at risk for potential unidentified neglect and lack of protection from abuse/neglect. Findings included . Review of the Nursing Home Guidelines, The Purple Book, revised in 2015, showed that all alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. Review of the facility's undated policy titled, Abuse Investigating and Reporting, showed all reports of resident abuse, neglect, exploitation and misappropriation of resident property shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Review of the quarterly Minimum Data Set (an assessment tool) dated 03/06/2025 showed Resident 1 was cognitively intact. Review of the complaint hotline form 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 timely develop a care plan for lice (insects that live on the human body and hair that can be transmitted through contact with an infected person or their belongings like clothing and /or bedding) infestation for 1 of 1 resident (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at increased risk for further infestation, and unmet care needs. Findings included . Review of the readmit Advanced Registered Nurse Practitioner (ARNP) progress note dated 03/04/2025, showed Resident 2 was readmitted to the facility that day, with orders for permethrin (treatment for lice) external liquid apply to hair and scalp one time. Review of Resident 2's care plan, initiated on 03/24/2025 [20 days later since the date of admission], showed, Resident 2 was on contact precautions for head Lice. In an interview on 3/27/2025 at 4:54 PM, Staff B, Interim Director of Nursing Services, stated that the care plan for Resident 2'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.

Based on observation, interview, and record review, the facility failed to ensure contact precautions (set of safeguards used to prevent the spread of infection transmitted through direct or indirect contact with a resident or their environment) signage was placed on the outside of the room for 1 of 1 Resident (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at increased risk of further infestation of lice (insects that live on the human body and hair that can be transmitted through contact with an infected person or their belongings like clothing and /or bedding) and related complications. Findings included . Review of the facility's undated policy titled, Isolation-Categories of Transmission Based Precautions, showed when a resident is placed on transmission-based precautions, appropriate notification is placed on the entrance door so that personnel and visitors are aware of the need and the type of precaution. The policy further showed the signage informed the staff of instructions for use of personal protective equipment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement their abuse policy and procedure by not ensuring reference checks were conducted prior to hire for 4 of 5 staff (Staff Y, Z, AA & BB), reviewed for reference checks. This failure placed the residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included . Review of the facility's policy titled, Abuse Prohibition Policy and Procedure, reviewed on 02/23/2021, showed, The Center will implement an abuse prohibition program through the following: screening of potential hires .The center will screen potential employees for a history of abuse, neglect, or mistreating patients/residents, including attempting to obtain information from previous employers. Review of employee records for Staff Y, Certified Nursing Assistant, Staff Z, Weekend Registered Nurse Manager, Staff AA, Nursing Assistant Registered, and Staff BB, Smoking Aide, did not show that reference checks were conducted by the facility prior to their respective hire dates. In an interview on 01/06/2025 at 12:34 PM, Staff…

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

Based on interview and record review, the facility failed to complete the required annual performance evaluations for 5 of 5 staff (Staff M, N, O, P & Q), whose personnel files were reviewed for Certified Nursing Assistant (CNA) performance evaluations. The failure to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews, placed residents at risk for receiving care from underqualified nursing staff and unmet care needs. Findings included . Review of the facility's policy titled, Performance Evaluations, revised in September 2020, showed, The job performance of each employee shall be reviewed and evaluated at least annually. Review of personnel file on 01/07/2025, showed Staff M, CNA, was hired on 12/02/2012. Further review showed that Staff M's most recent annual performance evaluation was completed on 07/15/2015. Review of personnel file on 01/07/2025 for Staff N, CNA, showed they were hired on 12/01/2012. Further review showed that Staff N's most recent annual performance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 appropriately store drugs and/or biologics (diverse group of medicines made from natural sources) for 2 of 3 medication carts (Medication Carts 2 & 3), reviewed for medication storage. This failure placed the residents at risk for receiving compromised/ineffective medications and potential adverse outcome. Findings included . Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed that the facility stored all medications and biologicals in locked compartments under proper temperature humidity and light controls. The policy showed the facility medications were stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle drawer, or other holding area to prevent the possibility of mixing medications of several residents. The policy further showed that multi-dose vials that had been opened or accessed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received current food menus and/or alternative menus that meets their needs including daily fresh fruits and vegetables for 5 of 6 residents (Residents 14, 309, 89, 55 & 52), reviewed for dining services. This failure placed the residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life. Findings included . Review of the USDA Dietary Guidelines for Americans 2020-2025 [retrieved on 01/15/2025], stated nutritional needs should be from nutrient dense foods such as vegetables from all vegetable subgroups like dark green; red and orange; as well as whole fruits. The recommended intake for an adult (Age 19 - 59): Vegetables: 2 - 4 cups/day; Fruits: 1 1/2 - 2 1/2 cups/day; (Age 60 and up): Vegetables: 2 - 3 1/2 cups/day; Fruits: 1 1/2 - 2 cups/day. Review of the facility's policy titled, Menus, revised on 09/2017, showed that menu cycles…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 4 of 4 residents (Residents 51, 27, 64 & 93), reviewed for infection control. In addition, the facility failed to ensure hand hygiene, proper glove use, and infection control practices were followed for 3 of 13 staff (Staff DD, Staff II & Staff V). These failures placed the residents, staff, and visitors at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Isolation-Initiating Transmission-Based Precautions, revised in August 2019, showed that Transmission-Based Precautions may include Contact Precautions and when Transmission-Based Precautions are implemented, the Infection Preventionist .clearly identifies the type of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to initiate and resolve a grievance for 2 of 4 residents (Residents 44 & 36), reviewed for grievances. The failure to resolve grievances for missing personal items and discharge planning placed the residents at risk for frustration, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Grievance/Concern, dated on 08/25/2021, showed that the purpose of the policy was To assure prompt receipt and resolution of Resident/Representative grievance/concern. It further showed, Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern and documented on the Grievance/Concern Log. When the formal grievance/concern is logged, the Administrator and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated .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 resident to resident altercations were thoroughly investigated for 3 of 5 residents (Residents 44, 55 & 46), 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, 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) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy further showed that the individual conducting the investigation at minimum .interviews staff members (on all shifts) who have had contact with the resident during 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 accurately assess 1 of 26 residents (Resident 36), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding collecting information during the entire look-back period for MDS Section L (Oral/Dental Status), Section N (Medications), Section O (Special Treatments, Procedures, and Programs), Section P (Restraints and Alarms) and Section Q (Participation in Assessment and Goal Setting), 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, The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate Preadmission Screening and Resident Reviews (PASARR-an assessment to ensure individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 2 of 6 residents (Residents 103 & 22), reviewed for PASARR screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, PASRR Completion Policy, revised on 9/30/2024, showed the facility will make sure that all admissions have the appropriate PASARR completed. The policy showed the facility's administrator would designate either the admissions director or the social worker to make sure the PASARR was done on all potential residents. The policy further showed the administrator would be accountable for monitoring 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 develop and/or implement care plans for 4 of 26 residents (Residents 39, 89, 17 & 99), reviewed for comprehensive care plans. The failure to implement care plans for edema (swelling caused by buildup of fluid in the body's tissues), nutrition, Range of Motion (ROM) and discharge planning placed the residents at risk for unmet care needs, complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plan Comprehensive, dated 08/25/2021, showed the facility's Interdisciplinary Team, in coordination with the resident or representative must develop and implement a comprehensive person-centered care plan for each resident. RESIDENT 39 Resident 39 admitted to the facility on [DATE] with a diagnosis of Lymphedema (a chronic condition that causes swelling in the body due to a buildup of lymph [fluid that is part of the body's immune system] fluid). Review of Resident 39's edema care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and revise the comprehensive care plans for 3 of 26 residents (Residents 36, 87 and 91), reviewed for care plan timing and revision. The failure to develop comprehensive care plans for discharge planning, smoking behaviors and oxygen use, placed the residents at risk for unmet care needs, burns, injury, and potential negative outcomes. Findings included . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.19.11, revised in October 2024, showed that The comprehensive care plan is an interdisciplinary (IDT) communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically .The overall care plan should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow physician's order in accordance with professional standards when administering medications for 3 of 11 residents (Resident 42, 43 & 46), reviewed for medication administration. These failures placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life. Findings included . A review of the facility's policy titled, Physician Orders, effective date 03/22/2022, showed they would ensure that all physician orders were complete and accurate. The policy showed that the Medical Records Department would verify that physician orders were complete, accurate and clarified as necessary. Whenever possible, the Licensed Nurse receiving the order would be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to the other health care disciplines will be transcribed on the appropriate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 effective resident centered discharge plan was in place for 1 of 5 residents (Resident 36), reviewed for discharge planning. The failure to develop a discharge care plan consistent with the resident's needs and/or the resident representative's expressed discharge goals, placed the resident at risk for unmet care needs, decreased self-morale, sadness, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Transfer or Discharge Resident-Initiated, showed that Resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility. It further showed, The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated. RESIDENT 36 Resident 36 readmitted to the facility on [DATE]. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 2 of 4 residents (Residents 8 & 65), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with getting out of bed, showers, and nail 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, Activities of Daily Living (ADLs), Supporting, revised in March 2018, showed, 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. It showed that support and assistance with hygiene included, bathing, dressing, grooming, and oral care. It further showed that support and assistance with mobility included, transfer and ambulation. RESIDENT 8 TRANSFERRED OUT OF BED Review of the quarterly Minimum Data Set (MDS-an assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for 3 of 5 residents (Residents 39,89 & 46), reviewed for quality of care. The failure to follow treatment orders for edema (swelling) and bowel management and/or the failure to notify medical providers for a significant weight gain placed the residents at risk for unmet care needs, pain/discomfort, and related complications. Findings included . Review of the facility's policy titled, Skin Integrity Management, dated 05/26/2021, showed that the implementation of an individual resident's skin integrity management occurred within the care delivery process. Review of the facility's undated policy titled, Weight Management, showed it was the facility's policy to obtain a baseline weight and identify a significant weight change and determine possible causes of the significant weight change. The policy showed that in the event of a patterned 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.

Based on observation, interview, and record review, the facility failed to ensure services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 1 of 3 resident (Resident 17), reviewed for ROM and mobility. This failure placed the resident at risk for unmet care needs, a decline in ROM, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set (an assessment tool) dated 12/04/2024, showed Resident 17 had limited ROM in their upper extremity on one side. Review of Resident 17's ROM care plan revised on 04/16/2020, showed interventions that included, LN [Licensed Nurse] applies right rigid resting splint for 3-4 hours and PROM [Passive ROM] to RUE [right upper extremity] .AROM [Active ROM] to LUE [left upper extremity]. Review of Resident 17's electronic health record showed no documentation for splint use and no documentation that PROM and AROM was provided for Resident 17. Observations on 01/03/2025 at 9:09 AM and on 01/04/2025 at 2:08 PM, showed Resident 17 was not wearing any splints. In an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow and implement smoking assessment and care plan, and did not ensure smoking materials were securely maintained for 1 of 10 residents (Resident 91), and failed to ensure side rails were secured and maintained for 1 of 2 residents (Resident 34), reviewed for accident hazards. These failures placed the residents at risk of potential burns, injury, potential harm and other negative outcomes. Findings included . In a meeting with Staff C, Interim Administrator, Staff A, Administrator and Staff B, Director of Nursing, on 01/02/2025 at 10:40 AM, a request for documentation of the facility's list of residents who smoke, designated smoking times, locations as well as the facility's smoking policy. Staff C and Staff B stated that the facility was a Smoke-Free Center, and that their current list of residents who smoked were grandfathered participants. Documentation of the facility's smoking policy was not provided. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 2 of 3 residents (Residents 22 & 87), reviewed for respiratory care. The failure to follow physician orders for oxygen therapy, and properly store oxygen equipment placed the residents at risk for respiratory infections and related complications. Findings included . Review of the facility's policy titled, Oxygen Administration, revised in October 2010, showed, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. RESIDENT 22 Review of the Quarterly Minimum Data Set (an assessment tool) dated 10/11/2024, showed Resident 22 was cognitively intact and that they received oxygen therapy. It further showed that they had diagnoses that included chronic obstructive pulmonary disease (a condition that blocks air flow and make it difficult to breathe). Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure foods were served at proper temperature for 2 of 5 nursing units (500 and 200 Unit), and 6 of 6 residents (Residents 7, 3, 6, 4, 5 & 1), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life. Findings included . FOOD TEMPERATURES 500 NURSING UNIT During a joint observation and interview on 12/12/2024 at 12:55 PM with Staff D, Corporate Dietary Manager (CDM), showed Staff D used the facility's kitchen thermometer to check the temperature of a cooked chicken patty that was delivered to the 500 nursing unit, the tray was removed from a closed cart which, contained individual, closed plastic containers with the resident's lunch meals. A chicken patty temped at 100 degrees Fahrenheit (F), interview at this time with Staff D stated that the temperature for the chicken patty to be served to the residents should be 135 degrees…

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

Based on observation, interview, and record review, the facility failed to have a boiler that consistently supplied hot water to the kitchen sink for dishwashing for 1 of 1 kitchen, reviewed for essential equipment. This failed practice caused the meals to be served from plastic containers that did not keep the meals at proper temperatures when served to residents and had the potential to cause weight loss and a diminished quality of life. Findings included . During a joint observation on 12/12/2024 at 12:21 PM with Staff C, Dietary Manager and Staff D, Corporate Dietary Manager, showed a small white sink was observed in the kitchen with a white tube (approximately six feet long) taped with gray (duck) tape around the faucet fixture that held the tube to the faucet fixture. In an interview on 12/12/2024 at 12:24 PM Staff C, stated it was the only sink in the kitchen that had hot water to wash the pots, pans, and trays that held the plastic containers with meals for the residents. Staff C stated the dietary staff put the end of the white tube into a large pan, filled the pan with hot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 AMENDED ARE IN BOLD. Based on observation, interview, and record review, the facility failed to take timely action and/or document the reason for delayed dental treatment for 1 of 3 residents (Resident 1), reviewed for dental care services. The failure to provide timely dental care services placed the resident at risk for dental pain, decline in nutritional status, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set assessment (MDS - an assessment tool) dated 01/24/2024 showed the resident readmitted to the facility on [DATE]. The MDS assessment showed the resident had intact memory. On 02/06/2024 at 2:42 PM, Resident 1 stated, I don't have any teeth and when the food hits my gums it hurts, so I don't eat very much because I can't. I drink the milk shakes to keep from losing too much weight, it's not as bad as when I try to chew food. I just need some dentures, even soft foods hurt to chew. I was supposed to get dentures a long time ago. I don't know what happened.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meals that accommodated resident food allergies and preferences for 1 of 2 residents (Resident 1), reviewed for food allergies/preferences. This failure placed the resident at risk for allergic reaction, dissatisfaction with food, weight loss, and a diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool) dated 08/28/2023 showed Resident 1 was cognitively intact and received therapeutic diet. Review of Resident 1's allergy record dated 08/22/2023 showed Resident 1 was allergic to egg white that could cause an anaphylactic reaction (or anaphylactic shock is a severe, potentially life-threatening allergic reaction that can develop rapidly, signs include itchy skin or a raised, red skin rash, swollen eyes, lips, hands, and feet). Review of the progress notes dated 10/11/2023 at 5:18 PM, showed Staff C, Registered Dietitian, stated that the 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 interview and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff D) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . Review of the facility's policy titled, Dietician, dated 10/2017, showed . A qualified, competent, and skilled Dietician [health professionals who are experts in diet and nutrition] will help oversee the food and nutrition services of the facility. A qualified Dietician or other clinically qualified nutrition professional will help oversee food and nutrition services provided by the residents. If a dietician is not employed full time (35 or more hours per week) a director of food served management will be designated. This individual will. be a certified dietary manager. have an associate's (or higher) degree in food service management or hospitality. Receive frequent scheduled consultations from a qualified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 grievances were initiated, logged, addressed, and resolved timely in response to concerns for 4 of 6 residents (Residents 9, 33, 19 & 22), reviewed for grievances. This failure placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the undated facility policy titled, Resident Council, showed that the Resident council response form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. Review of the July 2023 and August 2023 Resident Council Meeting Minutes, showed there were issues concerning not enough staff and delayed call light response. RESIDENT 9 On 09/11/2023 at 2:00 PM, Resident 9 stated that during the January 2023 monthly council meeting, there were concerns about call lights not being answered in a timely manner. Resident 9 further stated that Staff S, Activity Director, was at the meeting and would take any concerns to the Administrator.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, the facility failed to ensure food were served at proper temperature for 8 of 8 residents (Residents 58, 38, 83, 44, 73, 56, 74 & 54), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life. Findings included . Review of the undated facility policy titled, Food Preparation and Service, showed the . Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Proper hot and cold temperatures are maintained during food distribution and services. RESIDENT 58 On 09/10/2023 at 7:02 AM, Resident 58 stated the food was cold. Review of Resident 58's annual Minimum Data Set (MDS - an assessment tool) dated 07/04/2023, indicated the resident was cognitively intact. RESIDENT 38 On 09/10/2023 at 7:22 AM, Resident 38 stated the food was not hot when served. Review of Resident 38's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to ensure damaged wheelchair armrests were repaired and/or replaced for 1 of 1 Resident (Resident 17), reviewed for comfortable/safe equipment use. This failure placed the resident at risk for unsafe equipment, potential injury, and a diminished quality of life. Finding included . Resident 17 admitted to the facility on [DATE] with diagnosis that included dependence on wheelchair. Review of Resident 17's quarterly MDS (an assessment tool) dated 06/20/2023, showed Resident 17 was using a wheelchair as a mobility device. Observations on 09/10/2023 at 12:41 PM, and on 09/11/2023 at 12:46 PM, showed Resident 17 was sitting in their manual wheelchair. Further observation showed the wheelchair's protective cover for both arm rest were ripped/missing, and the sponges were exposed. On 09/11/2023 at 12:50 PM, Resident 17 stated their wheelchair arm rest protective cover had been ripped/broken for a while and that they would like to have their wheelchair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a written transfer/discharge notices to the resident and/or the resident's representative and to the Office of the State Long-Term Care Ombudsman (an advocacy group for residents) describing the reason for transfer for 1 of 3 residents (Resident 42) reviewed for hospitalization. This failure placed the residents at risk of not having the opportunity to make informed decisions about transfers and access to an advocate who informed residents about options and resident rights. Findings included . Review of the facility's policy titled, Transfer or Discharge Notice revised in March 2021, showed that if an immediate transfer or discharge is required by the resident's urgent medical needs, the transfer or discharge notice is given to the resident and representative as soon as it is practicable but before the transfer or discharge. The policy also showed that a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 bed hold notices were provided at the time of transfer for 3 of 3 residents (Residents 42, 59 and 86) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed-Holds and Returns, revised in March 2022, showed that all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours). RESIDENT 42 Resident 42 admitted to the facility on [DATE]. Review of Resident 42's electronic progress notes dated 07/11/2023,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure admission assessments were completed within 14 days of admission for 2 of 15 residents (Residents 86 & 199), reviewed for comprehensive assessments. This failure placed the residents at risk for 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, Version 1.17.1, revised October 2019, showed the RAI process stated that the MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the Care Area Assessments (CAAs) completion date, but not later than. The CAA(s) completion date (item V0200B2) must be no later than day 14. RESIDENT 86 Resident 86 admitted to the facility on [DATE]. Review of Resident 86's admission MDS dated [DATE], showed it was completed on 08/21/2023, four days late. The admission MDS should be completed within 14 days, as required. RESIDENT 199 Resident 199 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment was conducted after the determination that hospice (end of life care) services no longer required for 1 of 1 resident (Resident 38), reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for 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, Version 1.17.1, revised October 2019, showed that a significant change in status assessment is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The Assessment Reference Date must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and transmit resident assessment data according to the required timeframe for 1 of 3 residents (Resident 42), reviewed for timeliness in completing and transmitting discharge tracking records. This failure placed the resident at risk of 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, Version 1.17.1, revised October 2019, showed Discharge Minimum Data Set (MDS) assessments must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500B + 14 days) to the database as required. Resident 42 admitted to the facility on [DATE]. Review of a progress note dated on 08/28/2023, showed Resident 42 discharged to the hospital. Review of Resident 42's MDS assessments, showed no discharge MDS was created and completed for the discharge date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately assess 3 of 24 residents (Residents 29, 38 & 77) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding participation of assessment/goal setting (Section Q) and Brief Interview for Mental Status (BIM - to assess cognitive patterns) placed the residents at risk for unidentified 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, Version 1.17.1, dated October 2019, showed Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). RESIDENT 29 Resident 29 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the baseline care plan was completed within 48 hours of admission and ensure a summary of the baseline was provided to the resident and/or their representative for 1 of 15 residents (Resident 199), reviewed for baseline care plan. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Resident 199 admitted to the facility on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE], showed the resident was cognitively intact. Review of the Post admission Patient [resident]-Family Conference form dated 09/10/2023, showed Section E (copy given to resident and/or their representative) was not marked or checked. Further review of the clinical records showed no information that a written summary of the 48-hour baseline care plan was provided to Resident 199 and/or their representative. On 09/10/2023 at 11:46 AM, Resident 199 stated that the facility did not provide them a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were developed for 1 of 24 residents (Resident 199), reviewed for comprehensive care plans. The failure to develop care plans for skin conditions and use of a Continuous Positive Airway Pressure (CPAP, a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing) machine placed the resident at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Skin Integrity Management, dated 05/26/2021, showed develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. Review of the facility's policy titled, Care Planning-Interdisciplinary Team, dated 08/25/2021, showed that a comprehensive care plan for each resident is developed within seven (7) days of the completion of the comprehensive assessment. The care plan is based on the resident'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 ensure residents and/or their representatives were invited to participate in care plan meetings/care conferences for 3 of 6 residents (Residents 29, 45 and 50), reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plan Comprehensive, dated 08/25/2021, showed the . Interdisciplinary Team is responsible for evaluation and updating of care plans . At least quarterly .The resident has the right to refuse to participate in the development of [their] care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies . RESIDENT 29 Resident 29 admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 29's was cognitively intact. 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 ensure showers/bathing were consistently provided for 2 of 4 residents (Residents 41 & 29), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for unmet care needs, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident's Rights, revised in December 2021, showed Employees shall treat all residents with kindness, respect, and dignity . guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence .to be supported by the facility in exercising [their] rights . Review of the undated facility policy titled, Resident Self Determination and Participation, showed Our facility respects and promotes the right of each resident to exercise [their] autonomy regarding what the resident considers to be important facets of [their] life .Each resident is allowed to choose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nutritional recommendation for Vitamin D (or Cholecalciferol, a supplement) was implemented for 1 of 1 resident (Resident 50), reviewed for nutritional management. In addition, the facility failed to ensure necessary care/treatment in accordance with professional standards of practice was followed for 1 of 1 resident (Resident 199), reviewed for skin condition. These failures placed the residents at risk for decline in health status, medical complication, and a diminished quality of life. Findings included . Review of the facility's policy titled, Nutrition/Hydration Care and Services, revised on 02/01/2023, showed the facility will review the Dietitian (health professionals who are experts in diet and nutrition) recommendations and obtain orders per recommendations. Additionally, it showed that the facility will contact the physician/advanced practice provider to convey the recommendations. RESIDENT 50 Resident 50 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 ensure supervision was provided for a safe use of e-cigarette (electronic cigarette) 1 of 1 resident (Resident 30), reviewed for e-cigarette/smoking management. This failure placed the resident at risk for burns, and avoidable accidents or fire. Findings included . Review of the U.S. Food & Drug Administration (FDA), dated 09/17/2021, showed to charge the vape on a clean, flat surface, away from anything that can easily catch fire and someplace they can clearly see it-not a couch or pillow where it is more prone to overheating or get turned on accidentally. Protect the vape from extreme temperatures by not leaving it in direct sunlight or in your car on a freezing cold night. Review of the facility's policy titled, Smoking, dated 08/09/2022, showed .Electronic Nicotine Delivery Systems (e-cigarettes) are products shaped like cigarettes, cigars or pipes that are designed to deliver nicotine or other substances to a user in the form of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure weekly weights were conducted for the first four weeks of admission to determine a baseline weight and failed to ensure nutritional supplements (health shake) at each meal was served for 1 of 1 resident (Resident 50) reviewed for nutritional management. This failure placed the resident at risk for significant weight loss, medical complications, and a diminished quality of life. Findings included . Review of the facility policy titled, Weight Management dated 08/25/2021, showed . weights will be obtained weekly for 4 weeks after admission .Notification of attending physician by nursing staff. The dietetics professional (experts in diet and nutrition) will assess the resident, document the assessment, and make recommendations in the resident's medical record. Orders may be obtained for nutritional supplements or other interventions. Resident 50 admitted to the facility on [DATE] with a diagnosis of failure to thrive. Review of the…

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