Avalon Care Center At Northpointe

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents (Residents 5 and 11) reviewed for medication administration. Specifically, medications were not held or administered when indicated, according to parameters ordered by the provider. This failure placed residents at risk for adverse health complications and diminished quality of life. Findings included. <Resident 5> A quarterly assessment, dated 03/31/2026, documented that Resident 5 had diagnoses of heart failure and high blood pressure. The resident was alert and made their needs known. Resident 5 had the following blood pressure medication orders: Lisinopril daily, hold for systolic blood pressure (SBP, the top number of a blood pressure reading) less than 110 or heart rate (HR) less than 60 beats per minute. Metoprolol ER (extended release) daily, hold for SBP less than 110 or HR less than 60. A review of the residents April and May 2026, Medication Administration Record (MAR) documented that the Lisinopril and Metoprolol ER was…

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

Based on interview and record review, the facility failed to administer methadone consistent with the dosage prescribed by Opioid Treatment Program provider and as a part of medications for opioid use disorder (MOUD) for 1 of 8 residents (Resident 1) reviewed for medication administration. This failure placed the resident at risk for medical complications, unintended health consequences and diminished quality of life.Findings included .Per the Code of Federal Regulations Title 42 Section 8.12 (h)(1) opioid treatment programs (OTP; a specialized clinic that provides medication-assisted treatment for individuals with opioid use disorder) must ensure that medications for opioid use disorder (MOUD) are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner and if consistent with Federal and State law. (2) OTPs shall use only those MOUD that are approved by 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 coordination with the opioid treatment program provider to change dosage of medications for opioid use disorder (MOUD) for 1 of 1 sampled residents, (Resident 1), reviewed for MOUD. This failure placed the resident at risk for medical complications, unintended health consequences and diminished quality of life.Findings included .Per the Code of Federal Regulations Title 42 Section 8.12 (h)(1) opioid treatment programs (OTP; a specialized clinic that provides medication-assisted treatment for individuals with opioid use disorder) must ensure that medications for opioid use disorder (MOUD) are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner and if consistent with Federal and State law. (2) OTPs shall use only those MOUD that are approved by the Food and Drug Administration under section 505 of…

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

Based on observation, interview, and record review the facility failed to store, discard and distribute food, and monitor temperatures of foods being served in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised 01/18/2023, showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be discarded as directed by the food manufacturer's use-by-date. The U.S. FDA Food Code 2022 also showed that there was an increased risk of contamination when food was held, cooled and reheated at improper temperatures. Thus, temperatures of food must be taken and monitored. Records must be maintained to verify food temperatures are within the parameters required for food safety. <Food Storage> During a kitchen observation and interview on 01/28/2025 at 9:07 AM, the walk-in refrigerator contained a crate of…

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

Based on interview and record review the facility failed to ensure the resident and/or the resident's representative was informed of and consented to a new medication for 2 of 3 sampled residents (Residents 54 and 90), reviewed for care planning. This failure disallowed the resident and/or the resident representative to make an informed decision regarding treatment and placed the resident at risk of diminished quality of life. Findings included Review of the facility policy titled, Resident Rights Notification of Changes of Condition dated July 2018, showed the facility would keep the resident and/or the resident representative informed of changes in health status. <Resident 90> According to the 11/26/2024 admission assessment Resident 90 had diagnoses including dementia, traumatic brain injury (TBI- brain damage caused by an external force), anxiety, and depression. Resident 90 had severe cognitive impairment with fluctuating inattention, disorganized thinking and no altered level of consciousness. Review of the 11/20/2024 hospital discharge medication list showed Resident 90 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Office of the State Long-Term Care Ombudsman (a person who acted as an advocate for residents that lived in long-term care) received written notification of a hospital transfer and/or discharges, as required for 5 of 6 sampled residents (Resident 4, 30, 46, 71 and 90), reviewed for hospitalization and discharge. This failure placed residents at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman, unmet needs, and diminished quality of life. Findings included . Review of the facility policy titled, Admission, Transfer and Discharge dated July 2018, showed the notifications to the Ombudsman office would occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. The policy further showed emergency transfer notifications would be sent to the Ombudsman at least on a monthly basis. <Resident 4> The 12/05/2025 discharge assessment documented Resident 4 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they were hospitalized , to the resident and/or their representative at the time of discharge or within 24 hours of transfer to the hospital for 5 of 5 sampled residents (Resident 4, 30, 46, 71 and 90), reviewed for hospitalization. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included <Resident 4> The 12/05/2025 discharge assessment documented Resident 24 was cognitively impaired and unable to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and depression. An 11/23/2024 progress note showed the resident had increased behaviors and was sent to the hospital. Additional record review found no documentation that showed the resident or their representative had been provided a bed-hold notice. <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 routinely encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 4 of 11 sampled residents (Residents 7, 12, 86 and 90), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11 revised October 2024, showed the RAI consisted of three basic components: the MDS, the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yielded information about a resident's functional status, strengths, weaknesses, and preferences, as well…

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 routinely timely and accurately complete Minimum Data Sets (MDS - an assessment tool) for 9 of 11 sampled residents (Residents 3, 12, 14, 39, 82, 83, 90, 109, and 510), reviewed for timely MDS assessment completion. This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11 revised October 2024, showed the RAI consisted of three basic components: the Minimum Data Set (MDS), the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three components of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, 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 observation, interview and record review, the facility failed to consistently monitor and provide bowel care timely for 7 of 7 sampled residents (Residents 23, 36, 54, 62, 4, 39, and 46) reviewed for constipation. This failure placed the residents at risk for medical complications and unmet care needs. Findings included . <Resident 23> The 11/21/2024 quarterly assessment documented Resident 23 was cognitively intact to make decisions regarding their care and was dependent on nursing staff for activities of daily living (ADLS) such as toileting. On 01/28/2025 at 3:51 PM, Resident 23 was observed lying in bed watching television. During the conversation with the resident, they stated they took pain medications and had trouble with constipation at times. Review of the Order Summary Report from 11/15/2024 through 02/04/2025 documented on 11/15/2024, the physician had ordered a laxative (Senna tablets) to be given on an as needed basis if the resident had not had a bowel movement (BM) in 48 hours, and if the resident still had not had a BM 24 hours after receiving the Senna, 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 falls were investigated, safety interventions implemented, and residents monitored after falls were sustained for 4 of 6 sampled residents (Residents 4, 14, 30,and 90), reviewed for falls. In addition, the facility failed to assess residents for risks associated with a substance use disorder (SUD) and their ability to safely smoke for 2 of 3 sampled resident (Resident 46 and 110), reviewed. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Fall Prevention Program dated February 2020, showed residents would be evaluated for fall risk upon admission, quarterly, and as needed. The policy showed all residents would be considered at risk for falls upon admission and general precautions implemented. A fall risk decision tree would be utilized to identify potential interventions specific for each resident with identified…

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 respiratory treatments had provider orders, that provider orders were carried out, and care plan goals and interventions were developed for 3 of 3 sampled residents (Residents 71, 358 and 359), reviewed for respiratory care. These failures placed residents at risk for respiratory complications and a diminished quality of life. Findings included . Review of the facility policy titled, Quality of Care Respiratory Care dated July 2018, showed the facility would provide residents with necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan and choices. The policy included a list of respiratory therapy modalities that could be provided at the facility which included breathing techniques, CPAP (continuous positive air pressure, a treatment that used pressure to keep the airway open by way of a mask) use, and oxygenation support. Staff were to assess and monitor a 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.

Based on interview and record review the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 2 of 5 sampled staff (Staff P and Y), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings included . Review of the following Nursing Assistant (NA) personnel files found no documentation that showed a yearly performance evaluation had been completed following: - Staff Y, Nursing Assistant - Staff P, Nursing Assistant In an interview on 02/03/2025 at 1:36 PM, Staff A, Administrator, stated they had not been aware there was not a process in place for completing yearly performance evaluations, and the facility was in the process of getting evaluations started. Reference (WAC): 388-97-1680 (1), (2)(a-c)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were not given psychotropic medications (medication that affected the mind, emotions, and behaviors) unless the medication was necessary to treat specific conditions documented in the clinical record, residents received non-medication behavioral interventions, and behavior and adverse side effect monitoring was consistently done for 3 of 6 sampled residents (Residents 22, 23 and 90), reviewed for unnecessary medications. This failure placed residents at risk of being chemically restrained, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Chemical Restraint dated November 2017, showed the facility would provide a safe environment that was free from abuse including the use of chemical restraints not required to treat the resident's medical symptoms. The policy defined a chemical restraint as any drug that was used for discipline or staff convenience and not required to treat…

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 3 of 5 sampled residents (Residents 22, 46 and 71), reviewed for medication administration, received medication as ordered by the physician. Failure to administer insulin, a medication used to treat diabetes, and consistently monitor blood sugar levels, a test done that checked the level of sugar in the blood stream, and failure to follow the parameters for holding a blood pressure medication created significant medication errors, and placed the residents at risk for medical complications, unintended health consequences and diminished quality of life. Findings included . INSULIN AND BLOOD SUGAR MONITORING <Resident 22> The 01/06/2025 quarterly assessment documented Resident 22 was able to make decisions regarding their care and had diagnoses which included high blood pressure and Diabetes, a medical condition caused when the body was unable to breakdown sugar. In addition, the assessment documented the resident received insulin, a medication used in the treatment of diabetes to keep blood sugar levels in the blood…

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 medications were stored under proper temperature controls in 2 of 3 sampled medication rooms (East and West) and in 1 of 3 medication storage refrigerators (East), reviewed for medication storage. This failure placed residents at risk of receiving less than the optimum dose of their medications, adverse side effects, and diminished quality of life. Findings included . <West Medication Room> During observation on 02/05/2024 at 1:16 PM, the [NAME] medication room was observed with Staff F, Licensed Practical Nurse. No thermometer was observed in the medication room where various medications were stored at room temperature. <East Medication Room> During observation, interview, and record review on 02/07/2025 at 7:42 AM, the East medication room was observed with Staff B, Director of Nursing. No thermometer was observed in the medication room where various medications were stored at room temperature. Staff B acknowledged the East medication room did not have a thermometer to monitor the temperature 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.

Based on observation, interview and record review, the facility failed to provide appetizing and palatable food for 5 of 9 sampled residents (Residents 18, 23, 36, 48 and 54) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, and a diminished quality of life. Findings included . <Resident 18> The 01/13/2025 quarterly assessment documented Resident 18 was cognitively intact and able to make decisions regarding their care. On 01/29/2025 at 9:05 AM, Resident 18 was observed in their room seated in their recliner. Resident 18 stated the food was not good, that the vegetables were mushy and any chicken they got was a processed patty. The resident stated they had been at the facility for years and could not remember when they had last seen a real chicken breast or real drumstick. Resident 18 stated the food was just thrown on the plate so that it did not look appetizing. They stated they had talked about their concerns with the dietary staff but there had been no results. <Resident 23> The 11/21/2024 quarterly assessment documented Resident 23…

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 arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Residents 14, 60, 90), reviewed for arbitration. This failure placed residents at risk of being uninformed of their rights, loss of legal protection, loss of right to pursue legal action and a diminished quality of life. Findings included . The Avalon Healthcare Management Patient and Facility Arbitration Agreement stated the parties understood that any dispute would be resolved by arbitration, and not by a lawsuit or court process. The policy further stated that the parties understood and agreed that by entering the arbitration agreement, they waived their constitutional right to a jury trial, and that by signing the agreement, they acknowledge they have read, 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 enhanced barrier precautions were implemented when indicated for 2 of 4 sampled residents (Residents 46 and 54 ) reviewed that had draining wounds and that hand hygiene was completed when indicated during 1 of 2 dining observations and 1 of 2 wound treatments observed. Additionally, N95 respirator-style masks were not donned correctly in accordance with the Centers for Disease Control (CDC) guidelines by 7 Staff (R, HH, II, JJ, X, T, and KK) when reviewing infection control practices, infection prevention and control policies were not reviewed yearly as required and a water management plan was not fully developed. These failures put residents and staff at risk of becoming ill with contagious viral and bacterial infections and spreading those illnesses to others. Findings included . The 04/02/2024 Centers for Disease Control (CDC) publication Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread…

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 a resident was evaluated to self-administer their medications for 1 of 5 sampled residents (Resident 74) reviewed for medication administration. This failure placed the resident at risk for missed medication doses or unintended health consequences. Findings included . The 11/04/2024 quarterly assessment documented Resident 74 had diagnoses that included bipolar disorder (episodes of manic highs and depressive lows), high blood pressure and cervical cancer. Resident 74 was cognitively intact and took antidepressant medication daily. On 01/29/2025 at 9:35 AM, Resident 74 was observed in their room seated on their bed with their overbed table in front of them. Several loose pills were on the table lying on a surgical mask. Included were four round white tablets, one pink round pill, one orange oblong tablet, one blue capsule, and one football shaped pill that was red on one side and white on the other. The pills were not in a medication cup. Additionally, there was a small medication cup on the table 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 and interview, the facility failed to ensure the weekly menus and/or alternative menus were provided for 3 of 9 sampled residents (Residents 23, 36 and 48), reviewed for food. This failure denied residents the right to choose their meal preference, had the potential to negatively affect their nutritional needs and create a diminished quality of life. Findings included . <Resident 23> The 11/21/2024 quarterly assessment documented Resident 23 was cognitively intact to make decisions regarding their care. On 01/31/2025 at 9:20 AM, Resident 23 was observed lying in bed watching television. When asked how breakfast was, Resident 23 stated it was good, had sausage, but one time the meal looked like scraps, like someone had eaten and they were served the left-over plate. When asked if the facility handed out menus, Resident 23 stated the menus were not handed out, you had to ask for them and it usually took a couple days to get it, so by then you had missed a couple days of being able to choose what you wanted for the meal. In an interview on 02/03/2025 at 12:08 PM,…

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

Based on interview and record review, the facility failed to provide information on services and charges for those services not covered under the facility's per diem rate for 2 of 3 sampled residents (Resident 91 and 14), reviewed for advanced beneficiary notices. This failure placed residents at risk of incurring unknown debt, financial hardship and a decreased quality of life. Findings included . Record review showed a 12/31/2024 Notice of Medicare Non-coverage letter (NOMNC) had been given to Resident 91, which showed Medicare payment for physical therapy, occupational therapy, and skilled nursing care would end on 01/02/2025. Additional record review showed Resident 91 had received a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), however, the written notice was incomplete and failed to inform Resident 91 of the costs for continuing to reside in the facility. A NOMNC dated 12/20/2024 was given to Resident 14, which showed Medicare payment for physical therapy, occupational therapy, and skilled nursing care would end on 12/23/2024. No documentation was found on the…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 4 of 8 sampled residents (Residents 14, 39, 46 and 83), reviewed for environment. Specifically Resident 14 had a wheelchair that was not maintained in a sanitary manner, Resident 39 had a hole in their drywall in their room, and Residents 39, 46 and 83 had drywall that was in disrepair. This failure did not allow residents to enjoy a homelike environment. Findings included . <Drywall> Per the 10/13/2024 quarterly assessment, Resident 39 was severely cognitively impaired and unable to make their needs known. During an observation on 01/28/2025 at 2:38 PM, Resident 39 was sitting in their recliner. There were gauges out of the drywall behind their recliner and a hole that was approximately six inches long and an inch wide near the headboard toward the floor. Similar observations were made on 01/30/2025 at 9:24 AM, 01/31/2025 at 9:00 AM, 02/03/2025 at 10:21 AM and 02/04/2025 at 8:53 AM. Per the 12/04/2024 quarterly assessment, Resident 46 was cognitively intact and able to make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to thoroughly investigate potential allegations of abuse for 2 of 3 sampled residents (Residents 30 and 83), reviewed for abuse. The facility further failed to investigate falls for 2 of 6 sampled residents (Residents 4 and 14) reviewed for falls. Specifically, Resident 30 had a fall in which they alleged the call light had been removed by staff and the call light concern was not investigated and Resident 83 had a scabbed area on their arm allegedly caused by staff and the cause of the scab was not investigated to rule out abuse. This failure placed residents at risk of further potential abuse and diminished quality of life. Findings included . Review of the facility policy titled, Freedom from Abuse, Neglect and Exploitation revised November 2017, showed staff would conduct a thorough investigation of allegations. <Resident 83> In an interview and observation on 01/28/2025 at 2:49 PM, Resident 83 stated a week or two ago a nursing assistant…

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 resident's medical record contained documentation of a hospital transfer and/or that the receiving hospital had received information of the resident's condition, for 1 of 4 sampled residents (Resident 4), reviewed for hospitalization. This failure placed the resident at risk for a delay in treatment and unmet care needs. Findings included . The 11/23/2024 discharge assessment documented Resident 4 had cognitive impairment and had diagnoses which included diabetes, depression and anxiety. A review of Resident 4's transfer form dated 11/23/2024 documented the resident needed a proxy to make decisions and was being transferred to the hospital to be evaluated for behaviors such as agitation and psychosis. The area on the form which asked if the report had been called in to the hospital and to whom was blank.There was no further documentation that described what, if any, information was relayed to the hospital at the time of the resident's transfer. During an interview on 02/07/2025 at 9:01 AM, Staff M, Licensed…

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 Pre-admission Screening and Resident Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions], was completed after an exempted hospital stay for 1 of 5 sampled residents (Resident 46), reviewed for PASARR services. This failure placed the resident at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs. Findings included . Per the [DATE] quarterly assessment, Resident 64 admitted to the facility in [DATE] from the hospital and had diagnoses which included depression and anxiety. Review of Resident 46's record showed a level I PASARR was completed prior to admission on [DATE] by the hospital, which showed a level II PASARR (a more in-depth screening, to identify whether nursing home services were needed, and if specialized mental health services were required), was needed, due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prepare a discharge summary that included all the required components, complete a final summary of the resident's status upon discharge, complete a discharge plan of care with all the required components, and convey discharge information to the provider continuing care for 2 of 6 sampled residents (Residents 90 and 110), reviewed for discharge. This failure placed residents at risk of unsafe discharges, unmet care needs and diminished quality of life. Findings included . <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. Resident 90 had severe cognitive impairment. Review of the 01/24/2025 discharge summary showed Resident 90 discharged from the facility to the community. Review of the January 2025 nursing progress notes showed Resident 90 was scheduled to discharge on [DATE]. The last progress note in Resident 90'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 interview and record review, the facility failed to ensure a staff member was available to provide assistance to a resident while they were at an appointment with a provider outside the facility and failed to provide bathing as care planned for 2 of 4 sampled residents (Resident 109 and 54) reviewed for activities of daily living. Findings included . <Resident 109> The 12/26/2024 admission assessment documented Resident 109 was severely cognitively impaired, was dependent on nursing staff for activities of daily living (ADLS) such as toileting and had diagnoses which included medically complex conditions. Review of the State Agency's reporting database showed a concern had been reported which documented Resident 109 was wheelchair bound and had conditions that required a caregiver to be with them while attending appointments with providers outside the facility. The report further documented on 01/06/2025, Resident 109 had been dropped off at an appointment without a caregiver and while at the appointment, the resident needed assistance to the bathroom. Review of the ADL…

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 identify a pressure ulcer and implement treatement timely for the development of a wound for 1 of 2 sampled residents (Resident 54), reviewed for pressure ulcers. This placed the resident at risk for unidentified wounds, worsening pressure ulcers and delayed wound healing. Findings included . Review of the facility policy titled, Quality of Care Skin Integrity dated 08/2018, showed the facility staff would monitor residents skin conditions and be alert to potential changes in the residents' skin condition and identified changes would be reported. The website nih.gov - in which nih refers to national institute of health- with regard to the revised National Pressure Ulcer Advisory Panel pressure injury staging system showed a pressure injury is localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure…

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 physician ordered foot care referral for a podiatrist was followed for 1 of 2 sampled residents (Resident 54), reviewed for wound care. This failure placed the resident at risk for skin impairment, discomfort, and a diminished quality of life. Findings included . Per the 10/22/2024 quarterly assessment, Resident 54 had diagnoses which included diabetes, Multiple Sclerosis (a disease in which the immune system breaks down the protective covering of the nerves and the resulting nerve damage disrupts communication between the brain and the body), and depression. The resident was cognitively intact and able to make their needs known. In an interview on 01/28/2025 at 10:53 AM, Resident 54's representative stated the resident's toenails were extremely bad and had curled over their toes. The representative stated they were told the facility could not get a podiatrist to come into the facility. The representative stated the nurse practitioner did the resident's toenails on 01/27/2025. Review of a 09/30/2024 provider…

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 consistent, ongoing communication and collaboration with the dialysis facility for 1 of 2 sampled residents (Resident 23) reviewed for dialysis, a treatment that removed waste products and excess fluid from the bloodstream when the kidneys no longer functioned properly. In addition, the facility failed to ensure Resident 23's care plan included accurate goals and interventions related to the care and maintenance of the central venous catheter (CVC: a flexible tube that was inserted into a vein to provide an access site for dialysis). Findings included . The 11/21/2024 admission assessment documented Resident 23 was cognitively intact to make decisions regarding their care and had diagnoses which included diabetes and end stage kidney disease. In addition, the assessment documented the resident received dialysis via an intravenous access site. In an interview on 01/28/2025 at 3:27 PM, Resident 23 was observed lying in bed watching television. During the conversation, the resident stated they received…

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 facility had enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 3 of 8 sampled residents (Resident 83, 90 and 110), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment updated December 2024, showed the facility was licensed for 119 beds with an average daily census of 88. The assessment further showed the facility provided care related to fall prevention, behavioral health needs, substance use disorders (SUD), nutrition services, pressure injury prevention and care, and infection prevention practices. The facility employed a staffing coordinator to assist with facility staffing needs. The assessment further showed the facility leadership…

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 monitoring of potential adverse effects from a blood thinning medication was done consistently for 1 of 5 sampled residents (Resident 22) reviewed for unnecessary medications. This failure placed the resident at risk for medical complications, unmet care needs and adverse side effects. Findings included . <Resident 22> The 01/06/2025 quarterly assessment documented Resident 22 was able to make decisions regarding their care and had diagnoses which included heart failure and high blood pressure. In addition, the assessment documented the resident was taking a blood thinning medication. The provider orders documented Resident 22 was prescribed a blood thinning medication (Xarelto). Additional orders included instruction to the licensed staff to monitor for adverse reactions such as bleeding, severe bruising, difficulty breathing or chest pain. Review of the January 2025 Medication Treatment Record on 01/31/2025 found on the following dates and shifts, the monitoring documentation for adverse side effects of the blood…

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 beds were in safe operating condition for 4 of 26 beds in use on the [NAME] nursing unit observed. Specifically, bed controls had wires exposed and old electrical tape that had peeled off for 4 resident beds. This failure put residents at risk of injury and of being deprived of a home-like environment. Findings included . On 01/29/2025 at 9:35 AM, Resident 74 was observed in room [ROOM NUMBER]-1 seated on their bed. The bed control was observed to have wiring exposed where the wiring entered the portion that had buttons for adjusting the position of the head or foot of the bed. The resident stated they were unsure when the wiring became exposed. There were no frayed wires present. On 01/29/2025 at 10:18 AM, Staff K, Maintenance Director had replaced the bed in room [ROOM NUMBER]-1 and was observed pushing the bed with the exposed wiring down the hall. On 01/29/2025 at 10:25 AM, further resident bed observations identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call bells were in working condition for 2 of 50 residents observed (Residents 4 and 74) housed on the [NAME] nursing unit. This failure placed residents at a safety risk of having their urgent needs unanswered and unintended health consequences. Findings included . <Resident 74, room [ROOM NUMBER]-1> On 01/29/2025 at 9:35 AM, Resident 74 was observed in their room seated on their bed. The call light cord was observed pulled out of the wall, coiled up in a cardboard toilet paper roll and was placed on top of the chest of drawers. The call light system at the wall over the resident's head of their bed had green painter's-type tape over the button that turned off the light if it had been activated. Resident 74 stated their call light had not functioned for a couple of weeks. Resident 74 stated previously the light did not shut off and they had removed the cord the previous day. Resident 74 stated they had notified Staff 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 resident personal refrigerators were maintained in a clean manner, without expired foods and at the appropriate temperatures for 2 of 5 sampled residents (Residents 74 and 51) reviewed for a homelike environment. This failure placed the residents at risk of eating spoiled foods and having an unclean environment. Findings included . <Resident 74> During an interview on 01/29/2025 at 9:35 AM, Resident 74 was observed seated on the edge of their bed. A small dormitory-style refrigerator was on the floor next to the head of the bed. Inside the refrigerator, a brown liquid had been spilled on the bottom. A can of soft drink rested in the liquid, and a supplement drink was on the shelf. Resident 74 stated they were given the refrigerator when another resident got a new one. They stated they kept drinks and snacks in it, but were unsure who kept track of refrigerator temperatures.They stated there was no temperature log in their room. On 01/31/2025 at 9:40 AM, Resident 74's refrigerator no longer had a brown…

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 allegations of potential misappropriation were reported immediately to facility administration and the State Survey Agency as required, for 1 of 5 sampled residents (Resident 9) reviewed for abuse/neglect. This failure placed the resident at risk for abuse. Findings included . Review of Resident 9's November 2024 progress notes showed an entry on 11/14/2024 by Staff C, Social Services, which documented the resident reported an allegation that a staff member was rough with the resident. Review of the facility's Incident Log for November 2024 did not show any entries related to Resident 9. In an interview on 12/10/2024 at 2:29 PM Staff C confirmed Resident 9 reported an allegation of abuse to them on 11/14/2024. Staff C stated they reported the resident's allegation the same day and unidentified staff were investigating the incident while Staff C was out of the facility. Staff C stated they returned to the facility on [DATE] and were directed to…

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

Based on interview and record review the facility failed to provide the necessary care and services for 1 of 4 residents (Resident 3), reviewed for wound care. Failure to perform wound treatments as ordered placed the resident at risk for delayed wound healing, worsening of wounds, and/or potential infection and a diminished quality of life. Findings included . Review of the October 2024 Treatment Administration Record for Resident 3 showed an order for wound vacuum therapy (treatment consisting of a specialized dressing and a machine that applies gentle suction to a wound to aid in healing) at 125 mmHg (millimeters of mercury; a unit of pressure). The order showed the dressing was to be changed every Tuesday, Thursday, and Saturday. Review of Resident 3's October 2024 progress notes showed the following: - On 10/09/2024 the resident admitted to the facility with an open surgical wound to their abdomen that required a wound vacuum dressing, which would be applied by the wound nurse the following day (10/10/2024). - On 10/11/2024 Staff D, Registered Nurse, documented 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.

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 1 of 3 sampled residents (Resident 1), reviewed for misappropriation. This failure placed residents at risk for pain and a diminished quality of life. Findings included . Review of the pharmacy policy titled, LTC Facility's Pharmacy Services and Procedure Manual, revised 08/01/2024, showed the facility should maintain separate records on controlled substance medications and medications with a potential for abuse or diversion. The facility should reconcile the total number of controlled medications on hand, add newly received medications to the inventory and remove medications that are completed or discontinued from the inventory, pursuant to the controlled substance shift count sheet (logbook). Review of a 09/11/2024 facility investigation report showed Resident 1 reported receiving a pain pill that dissolved in their mouth three times during the past month from Staff B, Registered Nurse. Per the investigation the resident was alert and oriented and knew…

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 sufficient nursing staff to ensure showers were completed as careplanned and call lights were answered timely for 3 of 4 sampled residents (5, 6, 7) reviewed for activities of daily living (ADLs). This failure put residents at risk for skin breakdown, incontinence episodes, or unmet care needs. Findings included . <Resident 6> The 08/28/2024 quarterly assessment documented Resident 6 had diagnoses including morbid obesity and diabetes. Resident 6 was cognitively intact, and was dependent on staff for toileting, personal hygiene and bathing. The 11/29/2022 care plan documented Resident 6 had an ADL self-care deficit; They required substantial/maximum assistance of 1 staff to provide bathing/showering. Resident 6 preferred showers twice weekly and as necessary. The undated Nursing Assistant Care Card ([NAME]) documented Resident 6 preferred twice weekly showers on Tuesdays and Fridays. The Nursing Assistant Showering Task…

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 provider of a change in a resident's oxygen saturations for 1 of 4 sampled residents (Resident 1) reviewed for notification of changes. Failure to notify the provider of low oxygen saturations did not allow for interventions to be put in place prior to the resident's departure to the hospital. Findings included . A review of the record documented Resident 1 had diagnoses including pneumonia and heart failure (inability for the heart to pump blood efficiently to meet the needs of the body). The 08/22/2024 admission assessment documented Resident 1 was cognitively impaired, wandered and had behavioral symptoms. The 08/17/2024 care plan documented Resident 1 had altered cardiovascular status; Staff were instructed to assess the resident for shortness of breath, monitor vital signs and notify the provider of significant abnormalities, and apply oxygen at 2 liters by nasal cannula as needed. The 08/16/2024 hospital discharge orders included to give oxygen at 1-2 liters as needed for oxygen saturations less than 92%.…

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 assess a resident for removal of an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) for 1 of 3 sampled residents (Resident 9), reviewed for catheter use. Additionally, the facility failed to ensure indwelling urinary catheters were properly secured for 2 of 3 sampled residents (Resident 8 and 9). This failure placed the residents at increased risk of acquiring potentially preventable catheter associated urinary tract infections, pain, and urethral trauma. Findings included . Per the Centers for Disease Control 03/25/2024 Summary of Recommendations of the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html) indwelling catheters should be properly secured after insertion to prevent movement and urethral traction (pulling). <Resident 9> Review of the facility's policy titled, Urinary…

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 3 of 5 Licensed Nurses (Staff J, K, and L) were evaluated by the facility for competency with skills and techniques prior to working with residents with indwelling urinary catheters (flexible tube inserted into the bladder to drain urine). This failure placed residents at risk for clinical complications. Findings included . Review of the May 2024 Treatment Administration Records (TAR) for Resident 8 showed Staff K and L, Licensed Practical Nurses (LPNs) were responsible for care and monitoring of the resident's indwelling urinary catheter. Review of the May 2024 progress notes showed Staff J, LPN, was responsible for monitoring Resident 8's bladder and potentially placing a urinary catheter based upon the resident's status. Review of the June 2024 TAR for Resident 10 showed Staff J, K, and L all provided care and monitoring of the resident's indwelling urinary catheter. Per the TAR, each LPN flushed and irrigated the resident's catheter (procedure to remove any substances clogging the catheter). In an interview on…

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

Based on interview and record review, the facility failed to ensure blood pressure medications were held when indicated for 1 of 3 sampled residents (Resident 1) reviewed for medication administration. This failure put residents at risk for unintended health consequences related to low blood pressures. Findings included . A review of the record documented Resident 1 had diagnoses including hypertensive kidney disease (kidney damage caused by long term high blood pressure) and primary pulmonary hypertension (high blood pressure that affects the arteries of the lungs and causes the heart to work harder to pump blood to the lungs). The 08/22/2024 admission assessment documented Resident 1 was cognitively impaired and relied on assistance of staff for most of their activities of daily living (ADLs). A review of the 08/2024 medication administration record (MAR) documented Resident 1 had the following medication orders: -Lisinopril 40 milligrams (mg) once daily for hypertensive kidney disease; hold medication and notify the provider if the systolic blood pressure (SBP, the upper number…

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 promptly resolve resident grievances and provide written grievance decisions for 3 out of 3 sample residents (Resident 2, 6, 7), reviewed for grievances. In addition, the facility failed to establish a grievance policy with all the required components. These failures placed the residents at risk of having unresolved grievances and a diminished quality of life. Findings included . Review of the June 2024 through August 2024 Grievance Report Log showed blank spaces under the disposition of grievances for the following: -06/11/2024 Resident 7 aid concerns -06/17/2024 Resident 2 ants -07/29/2024 Resident 6 missing glasses -08/13/2024 Resident 7 activities and wound rounds -08/14/2024 Resident 7 nurse concerns -08/14/2024 Resident 7 food -08/15/2024 Resident 7 color urine In an interview on 08/23/2024 at 10:59 AM Resident 7 stated they had filed multiple complaints about their care at the facility and had provided grievance forms to Staff D, Social Services, and Staff F, Resident Care Manager, but the facility had never…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a care plan to address assessed risks for accident hazards for 2 of 8 sample residents (Resident 2 and 8) reviewed for care planning. This failure placed residents at risk of unmet care needs. Findings included . <Resident 2> Review of the 06/10/2024 hospital discharge orders showed Resident 2 had dementia (group of symptoms affecting memory, thinking, and social abilities) and was at risk for falls. A facility fall assessment dated [DATE] showed the resident received a fall risk score of 11, which indicated they were at risk for falls. Review of the care plan initiated 06/13/2024 showed no interventions related to the resident's identified fall risk. In an interview on 08/26/2024 at 1:07 PM Staff E, Resident Care Manager, stated Resident 2 was at risk for falls due to their fall assessment score and confirmed a care plan related to fall prevention was not present in Resident 2's record. <Resident 8> Review of a 08/12/2024 facility wander risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) and/or their representatives, reviewed for quality of care, received timely notification of a transfer to the hospital when the resident's condition declined. This failure placed the resident at risk of delayed access to care, inability to participate in care planning, and diminished quality of life. Findings included . Review of a 05/17/2024 nurse progress note showed Resident 2 was transferred to the hospital at 1:15 AM that day due to a change of condition. Per the note the resident was less alert than usual, disoriented, was pale, and their vital signs were outside the normal range, including a blood pressure that was unobtainable. The note showed the nurse on the oncoming shift was notified of the resident's transfer later that morning, and a voicemail was left for the resident's representative. There was no documentation showing the time of the representative notification. In an interview on 05/28/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess for and accommodate resident preferences and intolerances for 1 of 3 sampled residents (Resident 2) reviewed for nutrition. This failure placed the resident at risk for dissatisfaction with food, decreased nutritional intake, unplanned weight loss, and a diminished quality of life. Findings included . Review of the admission assessment dated [DATE] showed Resident 2 had a diagnosis of Crohn's disease (chronic inflammatory bowel disease), had an ostomy (an opening in the abdominal wall for intestinal waste to bypass portions of the intestine), and was at risk for malnutrition. Per the assessment the resident did not have a specialty diet ordered. Review of Resident 2's nutrition care plan, initiated 04/24/2024, showed the Registered Dietician (RD) would evaluate and make diet change recommendations as needed. According to the National Institutes of Health…

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 labs were obtained as ordered, for 1 of 4 sampled residents (Resident 5), reviewed for laboratory (lab) services. This failure placed the resident at risk for delayed treatment, and a decline in condition. Findings included . Review of Resident 5's November 2023 Medication Administration Record showed an order for the nurse to call in an order to the lab for a CBC (complete blood count; measures parts and features of the blood), CMP (complete metabolic panel; measures substances related to the body's chemical balance and metabolism) and CRP (C-reactive protein; measures level of inflammation in the body) was signed as completed on 11/19/2023 and 11/26/2023. Additionally, an order for the lab to collect a CBC and CMP was signed as completed on 11/22/2023. A laboratory report dated 11/20/2023 showed the CBC, CMP and CRP were completed and a low sodium level resulted. No interventions related to the low sodium level were noted in the resident's record. Additionally, no results for the repeated labs ordered 11/22/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that narcotics medications were accounted for and administered by nursing staff according to professional standards for 14 of 17 sampled residents (2, 12, 22, 43, 57, 71, 72, 76, 80, 131, 281, 410, 505, and 526) reviewed for unnecessary medications and medication administration. Specifically, narcotic medications were removed from the narcotic count books but not documented in the medication administration records {MARS} that they had been given, there were multiple entries in the narcotic count books that showed two nurses did not verify the counts were correct, and Resident 2's pain medications brought in from home were not inventoried, and six pills came up missing. These failures placed residents at risk for increased pain, decreased quality of life, and created an increased opportunity for drug diversion. Findings included . Narcotics doses removed from the counts but not documented as administered: <Resident 131> A 10/24/2023…

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.

Based on observation, interview, and record review, the facility failed to consistently monitor and provide bowel care timely for 2 of 3 sampled residents (25, 7, and 50), reviewed for constipation. This failure placed the residents at risk for medical complications and unmet care needs. Findings included . <Resident 25> Per the 08/04/2023 annual assessment, Resident 25 was cognitively intact to make decisions regarding care and needed total assistance from nursing staff to complete activities of daily living such as toileting. On 11/02/2023 at 11:21 AM, Resident 25 was observed sitting in their wheelchair in their room watching television. During the conversation about care, the resident stated they had problems with constipation at times, but received something to help when it happened. Review of the October 2023 Medication Administration Record (MAR) showed on 01/23/2023, the physician had ordered a laxative (Senna tablets) to be given if the resident had not had a bowel movement in 48 hours, and if there still was no bowel movement 24 hours after receiving the senna, 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.

Based on record review and interview, the facility failed to ensure 6 of 17 sampled residents (7, 13, 19, 45, 57, 72), whose medications were reviewed, received their narcotic medications as ordered, received the appropriate doses of medication, and were free from significant medication errors. These failures placed the residents at risk for uncontrolled pain, over sedation and diminished quality of life. Findings included . The Omnicare Policy, General Dose Preparation and Medication Administration last revised on 01/01/2013 documented the nurse needed to observe the resident's consumption of the medication and document when medications were given. <Resident 7> Per the 08/21/2023 quarterly assessment, Resident 7 diagnoses included Alzheimer's, anxiety and had severe cognitive impairments. Per review of the physician's orders, showed Resident 7 had orders for Ativan 0.25 milligrams (mg) three times per day to treat anxiety, and the medication was to be administered at 8:00 AM, 12:00 PM and 8:00 PM. A review of the narcotic log book (a book that tracks and documents the amount of…

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

Based on observations, interviews, and record review the facility failed to ensure resident's preferences for bathing were honored for 1 of 1 sampled residents (43), reviewed for choices. This failure placed the resident at risk for decreased quality of life. Findings included . According to the 09/18/2023 annual assessment, Resident 43 was able to make decisions regarding care, had diagnoses which included Rheumatoid Arthritis, a chronic inflammatory disease that caused swelling, stiffness and painful joints, and chronic pain. In addition, the assessment showed the resident required assistance from nursing staff to complete activities of daily living such as bathing. On 10/30/2023 at 9:58 AM, Resident 43 was observed sitting in their wheelchair in their room. When asked how they were doing, the resident stated their neck hurt and they missed the hot tub they had at home because it helped with the pain caused by the arthritis. When asked if they were allowed to take a tub bath at the facility, Resident 43 stated they preferred a tub bath, but the facility did not have a tub, only…

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 record review and interview, the facility failed to inform and provide written information concerning the right of their residents to formulate an advance directive for 2 of 4 sampled residents (22, 76) reviewed. This failure placed residents at risk of not being able to exercise their rights and not having their wishes honored. Findings included . The 11/2017 Resident Rights, Advance Directives facility policy documented that upon admission, if the resident had not formulated an advance directive, the facility was to inform the resident of their right to establish an advance directive and assist the resident in developing one. The medical record was to reflect that the discussion of advance directives occurred and the resident's acceptance or declination of assistance. <Resident 22> A review of the record showed Resident 22 had diagnoses including left lower leg fracture, and chronic obstructive pulmonary disease (COPD, inflammation in the lungs causing difficult breathing.) The record did not contain documentation that Resident 22 had been informed of their right to form…

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 recognize a reported incident as an allegation of possible abuse/neglect and therefore did not report to the state survey agency in the required timeframe, for 1 of 3 residents, investigated for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect. Findings included . According to an admission assessment dated [DATE], Resident 281 had a diagnosis of infection in the soft tissue of the leg. The resident was cognitively intact and was able to make their needs known. During an interview on 10/30/2023 at 11:30 AM, Resident 281 stated that most of the staff was good, but there was one aide that was mean and rude. The resident further stated they used the call light for help picking up their blanket that had fallen. The aide refused and repeatedly said to do it themselves. The resident reported they had not told any other staff about the incident. On 10/31/2023 at 4:25 PM, informed Staff A, Administrator and Staff B,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY *AMENDED - All Amendments are in bold Based on observation, interview, and record review, the facility failed to implement interventions necessary to prevent the development of a wound for 1 of 5 sampled residents (65), reviewed for pressure ulcers. This placed the resident at risk for developing pressure ulcers and delayed wound healing. Findings included . The facility's Quality of Care for Skin Integrity policy dated 08/2018 stated based on a resident's comprehensive assessment, will provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing unless the resident's clinical conditions demonstrates that they were unavoidable. Per the policy, a resident identified as at risk for developing pressure ulcers will have individualized interventions implemented to attempt to prevent pressure ulcers from developing, interventions will be monitored for effectiveness and the care plan will reflect the…

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

Based on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards for 2 of 3 sampled residents (7 and 22) reviewed. Resident 22 had no orders for the provision of oxygen and care of their nebulizer equipment and Resident 7's orders for their oxygen were not followed and their equipment was not maintained in a clean manner. This failure placed residents at risk for respiratory difficulties and infections. Findings included . <Resident 22> A review of the 09/24/2023 admission comprehensive assessment showed Resident 22 had diagnoses including chronic obstructive pulmonary disease (COPD, inflammation and increased mucous production in the lungs that causes difficult breathing.) Resident 22 was mildly cognitively impaired and wore oxygen both prior to admission and while a resident. On 09/18/2023, orders were obtained to give Resident 22 an albuterol nebulizer (medication administered by a mist that is breathed into the lungs using a mask that covers the mouth and nose) every 6 hours for COPD, and an ipratropium…

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

Based on observation, interview and record review, the facility failed to provide person-centered pain management for 1 of 3 sampled residents (131). Resident 131 was not offered non-pharmacological pain interventions, an ordered pain relieving gel was not available, and doses of narcotic pain medications were removed from the narcotic locked drawer, but not documented they were administered. These failures placed residents at risk for increased pain, and decreased quality of life. Findings included . A 10/24/2023 re-admission assessment showed Resident 131 had diagnoses which included chronic osteomyelitis of the right ankle and foot (infection of the bone), fibromyalgia (widespread muscle pain and tenderness), and borderline personality disorder, a mental illness that severely impacts a person's ability to manage their emotions. In addition, the assessment showed the resident was cognitively intact to make decisions regarding their care, had a surgical wound with dressings to the feet, had verbal behaviors directed towards others, and took anti-anxiety, anti-depressant, 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 identify a resident was taking an ordered medication twice a day, instead of once daily as ordered, for 1 of 5 sampled residents (27), reviewed for unnecessary medications. This failure resulted in the resident receiving twice the intended amount of the medication for 13 days, and placed them at increased risk for side effects such as low blood pressure, fainting and heart issues. Findings included . According to the website www.mayoclinic.org, the medication Tamsulosin is also known by the trade name of Flomax. According to a 10/11/2023 admission assessment, Resident 27 had diagnoses which included diabetes, high blood pressure and Benign Prostatic Hyperplasia (BPH or an enlarged prostate) which can make urinating more difficult. The resident was cognitively intact and able to make their needs known. The Medication Administration Record (MAR) for October 2023, showed Tamsulosin 0.4mg daily at bedtime, was started on 10/05/2023. This medication was used to treat the symptoms of BPH. A provider progress note, 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.

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 2 of 2 medication storage rooms. The facility failed to maintain temperatures to ensure medications were properly stored. The facility further failed to ensure narcotics were counted and locked in the permanently affixed narcotic containers for 2 of 2 medication rooms. This failure placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . During an observation on the east unit of the narcotic count on 11/06/2023 at 6:44 AM, there was a bottle of Ativan (medication used to treat anxiety) in the portable lockbox. Staff H, Registered Nurse stated the Ativan was from the Omnicell (a medicine storage unit that held commonly given medications for an emergency supply) stock, and since it was unopened it was not being counted during the change of shift narcotic…

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 dietary staff had the required qualifications (current Food Worker Cards) for 4 dietary staff (S, T, U and W.) This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . A review of the dietary cards showed the following: - Staff S, Dietary Aide's Food Service Card expired on 08/16/2023. - Staff T, Dietary Aide's Food Service Card expired on 09/12/2023 - Staff U, Dietary Aide's Food Service Card expired on 09/16/2023 - Staff W, Dietary Aide's Food Service Card expired on 11/06/2023 On 11/08/2023 from 10:40 AM to 11:30 AM, Staff U was observed working on the lunch meal preparation in the kitchen. On 11/09/2023 at 10:30 AM, Staff T Was observed prepping food in the kitchen. During an interview on 11/09/2023 at 10:30 AM, Staff V, Kitchen Manager acknowledged that they had not kept track of the expiration dates on the cards. They further reported that the staff were being notified to get the cards…

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 staff failed to perform hand hygiene when indicated during a dressing change for 1 of 5 sampled residents (Resident 69) reviewed for pressure ulcer management and during one meal observation on the [NAME] Unit. This failure placed residents at risk for contact with contaminated surfaces, contamination of wounds and spread of harmful bacteria. Findings included . <Resident 69> A review of the 10/03/2023 quarterly assessment documented Resident 69 had diagnoses including stage 4 pressure ulcer (a wound caused by pressure that extended to muscle, tendon or bone) and paraplegia (paralysis of the lower extremities). Resident 69 was cognitively intact and had two stage 3 pressure ulcers (a wound that has full thickness tissue loss with no bone, muscle or tendon exposed) present on admission, and one stage 4 pressure ulcer present on admission. The 07/06/2023 comprehensive care plan documented Resident 69 had pressure ulcers and had potential for more pressure ulcers related to immobility. Interventions included to provide…

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 offer 1 of 5 sampled residents (Resident 4), reviewed for pneumococcal vaccinations, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer the resident the opportunity to be vaccinated with a Pneumococcal conjugate vaccine (PCV13, PCV15, and/or PCV20), and a Pneumococcal polysaccharide vaccine (PPSV23) - vaccines to prevent the development of pneumonia. This failed practice had the potential to increase the risk for the resident to contract pneumonia. Findings included . Review of a Centers for Disease Control and Prevention (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, updated 02/13/2023, showed pneumococcal vaccination was recommended for adults aged 19 through 64 years with certain chronic medical conditions. The list of conditions included chronic lung disease and asthma. Per the CDC website, for those who had not previously received any pneumococcal vaccine it was recommended to give one dose of PCV15 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.