Bridges To Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform a resident and/or their representative of their health status in a timely manner for 1 of 3 residents (Resident 2), reviewed for resident rights. This failure placed the resident and/or their representative at risk of not being fully informed of changes in condition, making informed decisions, and ensuring that treatment aligns with the resident's goals and preferences.Findings included .Review of the admission record showed that Resident 2 was admitted to the facility on [DATE] with a diagnosis that included chronic respiratory failure (a long term condition where the lungs cannot get enough oxygen into the blood or cannot remove enough carbon dioxide [made of one [NAME] and two oxygen elements]).Review of the progress note dated 01/21/2026 showed that Resident 2 was decannulated (removal of a tracheostomy tube [a breathing tube inserted through a small opening in the neck into the trachea/ windpipe to help a person breathe, receive oxygen, 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 interview and record review, the facility failed to ensure an allegation of abuse and/or neglect was reported to the State Agency within the required timeframe for 1 of 3 residents (Resident 1), reviewed for abuse reporting. This failure placed a resident at risk for potential unidentified abuse and/or neglect and lack of protection from abuse and/or neglect.Findings included .Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, Neglect means: a) a pattern of conduct or inaction by a person or entity with a duty of care to provide the goods and services that maintain physical or mental health of a vulnerable adult, or that avoids or prevents physical or mental harm or pain to a vulnerable adult; or b) an act or omission that demonstrates a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health, welfare, or safety. Review of the guideline showed, Abuse - Mental as a willful verbal or nonverbal action that threatens, humiliates, harasses, coerces,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation of abuse and/or neglect was investigated timely and thoroughly for 1 of 3 residents (Resident 1), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and a diminished quality of life.Findings included .Review of the Nursing Home Guidelines, The Purple Book, revised in 2015 (sixth edition), 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 policy titled Abuse and Neglect Prevention and Reporting, revised in February 2026, showed, it is the policy of the [facility name] that all patients be free from abuse and neglect. Review of the policy showed, It is the policy of [facility name] to that all suspected, alleged, or actual cases of patient abuse or neglect, including injuries of unknown origin, shall be thoroughly and completely investigated and…

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

Based on interview and record review, the facility failed to implement care plan for 1 of 3 residents (Resident 1), reviewed for comprehensive care plan. The failure to implement care plan for droplet precaution (an infection control measure used to prevent the spread of germs [tiny organisms]) placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the facility's policy titled, Comprehensive Care Plan, dated July 2022, showed that, IDT [Interdisciplinary Team] will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights.Review of Resident 1's physician order dated 02/11/2026 showed an order for droplet precautions due to runny nose and increased secretions. The order further showed that Resident 1 was to remain in their room and may leave room for bathing.Review of Resident 1's care plan, printed on 03/25/2026, showed that the resident was recovering from respiratory symptoms that included a runny nose and increased secretions. The care plan further showed that…

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

Based on observation, interview and record review, the facility failed to ensure sufficient dietary support personnel were available for 2 of 8 residents (Residents 1 & 3), reviewed for food and nutrition services. This failure to provide the kitchen with adequate dietary staff left residents at risk for less than palatable meals, improperly prepared meals, foodborne illness, late food service, and other negative health outcomes.Findings included .Review of the facility provided document titled, Facility Assessment [a document developed and maintained by nursing homes that assessed the resident population and their care needs, the condition of the building, risks and threats to the building such as unique environmental risks etc., and the resources the facility would require to manage resident needs and safety including staff and equipment], revised on 01/13/2026, showed that the facility did not plan for the number of cooks needed to meet food and nutrition services requirements.RESIDENT 1Review of the physician's order dated 03/23/2026 showed that Resident 1 had an order to take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plans for 4 of 7 residents (Residents 7, 1, 6 & 4), reviewed for comprehensive care plans. The failure to implement care plans for use of benzodiazepine (a medication for seizures/epilepsy [a temporary, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movements, sensations, or awareness]), diuretic (medications that help move extra fluid out of the body), and antibiotic (medications to treat infections) placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy, titled Comprehensive Assessment and Care Planning, dated July 2022, showed its purpose it to ensure that all patients are comprehensively assessed using the patient assessment protocols. The policy further showed a chart review that included a review of the most recent physician orders and a review of medication and treatment records. 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 observation, interview, and record review, the facility failed to ensure the nurse staffing information postings were posted at the beginning of each shift for 3 of 4 days and failed to ensure the nurse staffing information posting was in a prominent location readily accessible to residents/representatives and visitors, reviewed for Nurse Staffing Information. These failures placed the residents/representatives and visitors at risk for not being fully informed of current nurse staffing levels and resident census information.Findings included .Review of the facility's undated policy titled, Staff Postings, showed, Staffing will be posted daily in a readable format in a prominent location in the facility. It further showed, the Director of nursing or designee will post the following information daily at the beginning of each shift. Observations on 07/30/2025 at 9:28 AM, showed that the nurse staff posting form labeled, Staffing Standard was dated 07/29/2025 and posted on the wall at the nurse's station behind the counter.Observations on 07/31/2025 at 8:14 AM, showed that the…

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

Based on interview and record review, the facility failed to ensure Medication Regimen Review (MRR- a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance] to identify and address potential problems) was completed for 1 of 5 residents (Resident 6), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Regimen Review and Reporting, dated January 2023, showed, The nursing center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days. It further showed, For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is…

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

Based on interview and record review, the facility failed to maintain proper temperature for 1 of 1 refrigerator (Medication Room Refrigerator), reviewed for medication storage. This failure placed the residents at risk of receiving compromised and ineffective medications.Findings included.Review of the facility's policy titled, Storage of Medication, dated January 2023, showed, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The policy showed that medications requiring refrigeration would be kept between 36 to 46 degrees Fahrenheit ( F - a scale for measuring temperature). The policy further showed that a temperature log or tracking mechanism would be maintained to verify that temperature has remained within accepted limits.Review of the facility document titled, Refrigerator and Freezer temperature logs, showed temperatures taken from the Med [Medication] room Fridge as follows:-On 12/02/2024, entry was blank/no documentation.-On…

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

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 7 residents (Resident 2), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during garbage disposal and resident care for 4 of 8 staff (Staff M, Staff G, Staff R & Staff C). These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included . Review of the facility's undated policy titled, Infection Prevention and Control Program, showed, For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities .device care or use. feeding tube [flexible plastic tube inserted into the stomach to deliver liquid nutrition], tracheostomy [procedure to help air and oxygen reach the lungs by creating an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff followed and implemented abuse and neglect policies and procedures for the protection of residents during a medication error investigation for 1 of 2 residents (Resident 4), reviewed for allegations of potential neglect. This failure placed the residents at risk for abuse and/or neglect.Findings included .Review of the facility's undated policy titled, Freedom from Abuse, Neglect, and Exploitation Abuse Definition, showed, Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff member.Review of the facility's undated policy titled, Freedom from Abuse, Neglect, and Exploitation Abuse Policies II, showed:-The facility will maintain and implement policies to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property.-Each allegation of abuse will be thoroughly investigated in an effort to determine if abuse, neglect,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the Office of the State Long-Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) of discharges and/or transfers, as required for 1 of 1 resident (Resident 11), reviewed for discharge process. This failure placed the residents at risk for lack of advocacy and possible unidentified or unmet care needs. Findings included . Review of the facility's policy titled, Transfer and Discharge, dated July 2022, showed, Prior to facility initiated transfer, the patient [resident] will be notified in writing by Social Services or Designee, the reasons for transfer in a language and manner they can understand. It further showed, The State Ombudsman Office will be sent a copy of the notice. Review of a face sheet printed on 08/04/2025, showed Resident 11 was admitted to the facility on [DATE] and discharged on 05/28/2025. Review of the discharge Minimum Data Set (an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff document medications and/or enter physician orders before administration of medication in accordance with professional standards for 2 of 4 residents (Residents 5 & 6), reviewed for medication administration. These failures placed the residents at risk for medication errors and negative outcomes.Findings included.Review of the facility's policy, titled Receiving and Documenting Physician's orders, dated August 2024, showed telephone/verbal orders would be entered into the Electronic Medical Record (EMR), and it would be double checked and received by a Registered Nurse (RN) or Licensed Practical Nurse (LPN), and then sent to the on-call physician to be double checked and signed.Review of the facility's policy, titled MEDICATIONS - Medication Pass Procedure, dated 12/17/2023, showed that all medications would be administered under physician orders as part of the physician's plan of treatment. The policy guidelines 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's representative was provided information about COVID-19 (an infectious disease-causing respiratory illness) vaccinations, including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record for 1 of 5 residents (Resident 5), reviewed for COVID-19 immunizations. This failure placed the resident at risk for COVID-19 infection and denied their representative of the right to make informed decisions.Findings included .Review of the Centers for Disease Control and Prevention online document titled, Staying Up to Date with COVID-19 Vaccines, dated 01/07/2025, showed that parents of children ages 6 months to 17 years should discuss the benefits of vaccination with a healthcare provider.Review of the facility's undated policy, titled, Influenza [flu-contagious respiratory illness], pneumococcal [protection against infections that can cause pneumonia (a lung infection)], and COVID-19…

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