Willowcrest Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure medications were accurately administered and controlled drugs were reconciled for 1 (R174) of 1 residents reviewed for medication error. R174 had an order for hydrocodone-acetaminophen 5-325 mg every four hours as needed for pain. On 5/24/2025 at 10:53 PM and on 5/25/2025 at 5:42 AM, Licensed Practical Nurse (LPN)-C administered Zolpidem (Ambien) 5 mg (a hypnotic) instead of the ordered hydrocodone-acetaminophen 5-325 mg. The medication error was not identified at the change of shift from night shift to day shift on 5/25/2025 when the narcotic medications were to be reconciled with the narcotic count sheets. Findings include: The facility policy and procedure titled Medication Administration General Guidelines dated 1/2024 documents: PROCEDURES Medication Preparation: . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule 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 did not ensure 1 (R22) of 5 residents medication was adequately monitored. R22's physician order for Metoprolol Tartrate 100 mg (milligrams) twice daily includes instructions to hold the medication if R22's systolic blood pressure is less than 120. R22's blood pressure is not being taken to ensure R22's systolic blood pressure is above 120 prior to administering this medication. Findings include: R22's diagnoses includes hypertension (high blood pressure). R22's physician dated 3/4/25 documents Metoprolol Tartrate Oral Tablet 100 mg (milligrams) (Metoprolol Tartrate). Give 1 tablet by mouth every morning and at bedtime for HTN (hypertension) hold for systolic < (less than) 120. Surveyor reviewed R22's April 2025 MAR (Medication Administration Record), May 2025 MAR, & June 2025 MAR. Surveyor noted included on these MARs with a start date of 3/4/35 documents Metoprolol Tartrate Oral Tablet 100 MG (Metoprolol Tartrate). Give 2 tablet by mouth every morning and at bed time for htn hold for systolic < 120. Surveyor noted under the section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure residents were free of significant medication errors for 1 (R174) of 1 resident reviewed with a medication error. R174 had an order for hydrocodone-acetaminophen 5-325 mg every four hours as needed for pain and Zolpidem (Ambien) 5 mg daily at bedtime for insomnia. On 5/24/2025, R174 received the scheduled dose of Ambien. On 5/24/2025 at 10:53 PM and on 5/25/2025 at 5:42 AM, Licensed Practical Nurse (LPN)-C administered Ambien 5 mg (a hypnotic) instead of the ordered hydrocodone-acetaminophen 5-325 mg. R174 received three doses of Ambien within 10 hours and R174 was sent to the hospital for altered mental status and complaints of intractable pain. Findings include: The facility policy and procedure titled Medication Administration General Guidelines dated 1/2024 documents: PROCEDURES Medication Preparation: . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the comprehensive assessment of a resident, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (R1) of 3 residents reviewed. The facility did not notify the physician of R1's low blood pressures as ordered. Findings include: R1 was admitted on [DATE] with diagnoses that included Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, anxiety, Dementia, Bipolar, Schizoaffective Disorder, Gastric Ulcer and Chronic Kidney Disease stage 3. R1 was hospitalized on [DATE] for a change in condition, low blood pressure, low heart rate and altered mental status. She readmitted to the facility on [DATE]. The hospital Discharge summary dated [DATE] documented: Patient found to have acute kidney injury and signs of dehydration. Patient was given IV (intravenous) fluids with resolution. Ultimately suspect patient's dehydration was a consequence of use of home diuretic. Therefore patient's diuretic was changed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not follow professional standards for food service safety to ensure dishes and utensils were properly handled properly after sanitization from the dishwasher. This had the potential to affect all 78 residents if they receive food from the kitchen. *Dietary staff were observed going from the dirty side of the dishwashing machine to the clean side without performing hand hygiene. Findings include: On 03/25/24 at 10:00 AM, Surveyor observed Dietary Aide (DA)-E at the dishwashing station. DA-E was rinsing dishes on the right side of the dishwasher and placing them in a tray. DA-E then opened the dishwasher and removed a tray of clean dishes and slid the tray down the counter. Surveyor noted DA-E was wearing gloves, however, DA-E did not change his gloves. Surveyor continued to observe DA-E and noted DA-E wore the same gloves while continuing to rinse dishes, place them on a tray and put in the dishwasher and then remove trays with clean dishes from the dishwasher. DA-E then began sorting through the clean silverware tray to the left 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, record review and interview, the facility did not implement an effective Water Management Committee, along with infection prevention with medication administration. This was observed with 1 (R38) of 4 residents observed with medication administration. The facility did not include a closed unit in their water plan, which has the potential to effect all 74 residents in the facility. - The facility has a closed unit with no water assessment to prevent Legionella. - R38's medications were administered in a unsanitary manner. Findings include: Surveyor reviewed the facility's policy and procedure Legionella Surveillance Policy dated 10/24/22. The policy indicates the facility will establish primary and secondary strategies for the prevention and control of Legionella infections. The Primary prevention strategy refers to the approaches to prevention and control of Legionella infections in health care facilities with no identified cases. The Guidelines include: 4.b. Legionella grows best in water temperature 77 degrees Fahrenheit -108 degrees Fahrenheit, particularly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not complete a performance review for 5 of 5 CNAs (Certified Nursing Assistants) reviewed. This had the potential to affect a pattern of all 78 Residents who reside in the facility as the 5 CNA's work throughout the building as needed. Findings include: Administrator (NHA-A) informed Surveyor on 3/29/24 at 3:37 PM that there is no policy and procedure for performance reviews of CNAs. NHA-A provided Surveyor with an email dated 3/29/24, at 3:23 PM from VP (vice president) of Human Resources (VPHR)-BB that states the facility does not have a formal evaluation process but according to the employee handbook the following is written: .Your supervisor will evaluate your performance in writing at least annually. The written evaluation form will be discussed with you. The emphasis will be to constructively review your strengths and weaknesses and to set new job performance goals. Surveyor notes the facility assessment, last updated 3/28/24, documents the following in regards to performance reviews for CNAs. .Required in-service training…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 8 of 8 staff chosen at random received QAPI (quality assurance performance improvement) training on the elements & goals of the Facility's QAPI program which is required for all direct and indirect staff. This practice had the potential to affect all 78 residents in the facility. The following direct care workers: Certified Nursing Assistant (CNA)-CC, CNA-DD, CNA-EE, CNA-FF, CNA-T, and Licensed Practical Nurse (LPN)-R did not receive the required QAPI training within the required time-frame of date of hire. The following indirect care workers Laundry/Housekeeping (LK)-GG and Dietary Aide (DA)-HH did not receive the required QAPI training. Findings include: The facility's Facility Assessment Tool policy, updated 3/28/24, contained the following information: .List all staff training and competencies needed by type of staff. The list of required training's does not include QAPI training. CNA-CC was hired by the facility on 10/01/17. CNA-DD was hired by the facility on 03/08/22. CNA-EE was hired by the facility on 6/22/20.…

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

Based on staff interview and record review, the facility did not ensure staff received the annual Compliance and Ethics training. This practice had the potential to affect all 78 residents in the facility. The facility did not provide staff with the required annual Compliance and Ethics training which includes all direct and indirect staff for Laundry/Housekeeping (LK-GG) and Dietary Aide (DA-HH) on an annual basis. Findings include: The facility's Facility Assessment Tool policy, updated 3/28/24, contained the following information: .List all staff training and competencies needed by type of staff. The list of required training's does not include Compliance and Ethics training. LK-GG date of hire is 10/27/18 for this facility. DA-HH date of hire is 2/7/23 for this facility. On 3/9/29 at 2:09 PM, Surveyor reviewed the training's for LK-GG and DA-HH and determined there is no documentation that LK-GG and DA-HH received the required Compliance and Ethics training. On 3/29/24 at 3:09 PM, Surveyor interviewed Dietary Manager (DM-JJ) in regards to the required Abuse training for DA-HH.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure direct care staff 5 of 5 Certified Nurse Aides (CNAs)(CNA-CC, CNA-DD, CNA-EE, CNA-FF, CNA-T), Licensed Practical Nurse (LPN-R), and indirect care staff Laundry/Housekeeper (LK-GG), and Dietary Aide (DA-KK) reviewed received behavioral health training to care for Residents diagnosed with mental, psychosocial, a history of trauma, or substance use disorder as indicated on the facility assessment. This deficient practice has the potential for all staff to lack current knowledge to work with the unique challenges mental health illnesses present. The facility did not provide staff with required annual training on the facility's behavioral health services. Findings Include: The facility's Facility Assessment Tool policy, updated 3/28/24, contains the following information: .The facility admits Residents with Psychiatric/Mood Disorders which include Psychosis, Depression, Bipolar, Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. The facility assessment documents that the…

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

Based on observation, record review and interview, the facility did not ensure pressure injury interventions were accurately implemented. This was observed in 1 (R57) of 5 residents reviewed for pressure injuries. *R57 was observed in bed with the air mattress at an incorrect setting. Findings include: On 03/24/24 at 10:11 AM Surveyor observed R57 laying in bed. The low air loss mattress was set at 300# (pounds). R57 appeared thin with defined bone structure. On 03/25/24 at 9:29 AM Surveyor observed R57 laying in bed. The alternating air mattress setting was at 300#. R57's medical record was reviewed by Surveyor. R57's current MD (Medical Doctor) orders indicate: Alternating pressure relief air mattress to bed, check settings/function Q (each) shift. Settings 100# (pounds) every shift. This had a start date of 2/22/24, and 3/21/24, for alternating pressure relief mattress. R57's 5-day MDS (minimum data set) assessment completed 2/28/24 indicates a weight of 84 pounds. R57 had a wound consult assessment for the sacrum completed on 3/18/24: Etiology (quality) Pressure MDS 3.0 Stage 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure 1 (R10) of 2 residents reviewed received appropriate services related to catheter care. R10 did not have a follow up appointment made as requested to see Urology after a hospitalization on 1/23/2024 per discharge recommendation. Findings include: R10 was readmitted to the facility on [DATE] after a hospital admission on [DATE] for acute cystitis with hematuria. R10 was admitted back to the facility with a foley catheter in place. Surveyor reviewed R10's discharge summary from the hospital from [DATE]. R10 experienced episodes of urinary retention requiring a straight catheter a few times while in the hospital requiring R10 to have a foley catheter placed and discharged back to the facility. Per discharge summary R10 was to have a follow-up appointment scheduled with urology in 3 weeks to be seen for a possible trial void and cystoscopy. Surveyor reviewed R10's medical record and noted R10 did not follow up with urology 3 weeks after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and interview, the facility did not provide adequate nutritional support to 2 (R21, R66) of 4 residents reviewed for Nutrition. *R21 sustained a weight loss in January 2024. The facility did not follow recommendations from the facility's dietician to implement weekly weights for R21. *R66 sustained a significant weight loss in January 2024. The facility did not follow recommendations from the facility's dietician to implement weekly weights for R66. Findings include: 1.) R21 was admitted to the facility on [DATE] with diagnoses of hypothyroidism and osteoporosis. Surveyor reviewed the facility's policy titled Weight Monitoring with a revision date of 12/21/22. The facility's policy reads: . 6.) Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation 8.) The threshold for significant weight change will be based on the following criteria: 1 month-5% weight change is significant; greater than 5 % is severe. 3 month-7.5% weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure a resident with a gastrostomy tube received the appropriate care and services for 1 (R63) of 2 residents with gastrostomy tubes. R63's water flush bag was not labeled for two days. Findings include: R63's diagnoses includes cerebrovascular accident (CVA) & dysphagia. The feeding tube care plan initiated 2/27/23 includes an intervention also dated 2/27/23 of Administer tube feeding formula, hydration, and flushes per order. The annual MDS (minimum data set) with an assessment reference date of 1/12/24 has a BIMS (brief interview mental status) score of 8 which indicates moderate cognitive impairment. R63 is assessed as being dependent for eating and is checked yes for tube feeding while a resident. The physician orders dated 12/6/23 documents at bedtime for supplemental nutrition run Osmolite 1.5 at 60 ml (milliliters) per hour for 8 hours via pump per PEG tube. Run water flush at 60ml/hr (milliliter per hour) via pump. Start infusion at 2100 (9:00 p.m.) and continue until 0500 (5:00 a.m.). The physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and interview, the facility did not ensure intravenous fluids were administered appropriately. This was observed with 1 (R57) of 1 residents observed with IVF (intravenous fluids). - R57 had a 1 liter bag of 0.9 sodium chloride being infused intravenously with no identifying factors to include name, date, rate, purpose of IVF. Findings include: Surveyor reviewed the facility policy and procedure Intravenous Fluid and Drug Administration General Policies dated 8/21. The policy includes: 9. The nurse will verify the the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution. On 3/24/24 at 10:13 AM Surveyor observed R57 in bed with IVF running. The IVF bag did not have a label, date, name, rate or any other identifiable prescribed information. The IVF bag was 0.9% sodium chloride 1000 ml (mililiters). R57 had a the IV inserted in their right hand. There was no date to identify the date of insertion. The IVF tubing had a circular device with the dial set at 50/hr running. 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, record review and interview, the facility did not ensure oxygen humidification was implemented. This was observed with 1 (R57) of 1 resident's observed with oxygen administration. -R57 had orders for oxygen humidification and this was not implemented. Findings include: On 3/24/24 at 10:13 AM Surveyor observed R57 in bed with oxygen administration at 3.5 lpm (liter per minute) via nasal cannula. There is no humidifier with the oxygen administration. On 3/25/24 at 9:30 AM Surveyor observed R57 in bed with oxygen administration at 2.5 lpm per nasal cannula. There is no humidifier with the oxygen administration. R57's medical record was reviewed by Surveyor. R57 has a physician order from 3/21/24 to change oxygen tubing and humidifier bottles weekly. R57's March 2024 Treatment Administration Record indicates the following: Change oxygen tubing and humidifier bottles weekly. On 3/26/24 at 9:20 AM Surveyor spoke with (Registered Nurse/ Unit Manager) RN UM-M. They did not know about the humidifier and thought maybe it was a batch type order. They will look into it. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the Facility did not ensure 2 (R72, R66) of 5 residents were free from unnecessary medications. *R72 was prescribed antipsychotic medication without a timely Abnormal Involuntary Movement Scale (AIMS) assessment. *R66 was prescribed antipsychotic medication without a timely Abnormal Involuntary Movement Scale (AIMS) assessment. Findings include: Facility policy entitled, Psychotropic Medications, revised on 10/24/22, documents: Residents should not received psychotropic drugs unless the medication is necessary to treat specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrator by monitoring and documentation of the resident's response to the medication .The indications for use of any psychotropic drug will be documented in the medical record .Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation .Residents who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles including the expiration date when applicable for 1 of 2 medication carts reviewed and 1 of 1 medication rooms reviewed. *The North team two medication cart also contained containers of eye drops that were either not labeled with an opened date, had an illegible opened date, or were expired. *The East medication room contained 13 bottles of Optum Daily Rescue supplement that were expired 8/2023. Findings include: The facility policy entitled, Medication Administration general guidelines, dated 01/23, stated: .b. The nurse shall place a date opened sticker on the medication .and enter the date opened c. Certain products or packaging types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. When date open expiration dating is not available from the manufacturer, the following may be considered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interviews, and record review, the facility did not ensure food was stored under sanitary conditions. These deficient practices had the potential to affect 72 of 74 residents residing at the facility. The kitchen was observed to have food debris on the floor and a sticky red residue. Open food items were not labeled and dated with a use by date. Findings include: On 1/9/23 at 10:00 AM, Surveyor conducted initial kitchen tour with Dietary Manager-J. Upon entrance to kitchen, Surveyor noted food debris on floor including crumbs from cookies and toasted bread. Kitchen floor outside refrigerator #2 was noted with a sticky, red residue. Surveyor reviewed the contents of Kitchen refrigerator #2 and noted the following items were opened without a use by date: Mayonnaise, Italian Salad dressing jar. On 1/9/23, at 11:15 AM, Surveyor made observations of the main dining room servery. Surveyor noted dry cereal including fruit loop cereal, crispy rice cereal, corn flakes cereal and raisin bran cereal in large plastic tubs on table in servery. Surveyor noted there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not provide residents with meals that were palatable, attractive and served at an appetizing temperature for 72 of 74 residents residing at the facility. Residents expressed dissatisfaction with meals reporting their food was cold, did not taste good and they did not received desired food preferences. Surveyor's sampled lunch tray had food temperatures that were not hot and were not appetizing and/or palatable. Findings include: 1.) In an interview on 1/9/2023, at 11:04 AM, R181 stated the food was very dry and due to swallowing guidelines, needed to take a sip of liquid between bites, but since the food was so dry, it takes more than one sip to get the food down. In an interview on 1/9/2023, at 2:03 PM, R7 stated any time chicken or pork are on the menu, they are burnt. R7 stated the meatballs and meatloaf are the only food items that do not get burnt. R7 stated if the food is not burnt, it is hard. R7 stated because R7's room was at the end of the hall, the food is cold. In an interview on 1/9/23, at 9:56 AM. R67A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice after an unwitnessed fall for 3 (R54, R71, and R52) of 5 residents reviewed for falls. *R54 had an unwitnessed fall on 9/11/22. Neurological checks were not always completed following the fall to assess for a change in mentation. * R71 had unwitnessed falls on 6/2/2022, 8/13/2022, and 8/22/2022. Neurological checks were not completed following the falls to assess R71 for a change in mentation. * R52 had an unwitnessed fall on 12/15/22. Neurological checks were not always completed following the fall to assess for change in mentation. Findings: On 1/11/25 the The facility policy and procedure titled Fall Prevention Management Guidelines dated 11/08/22 was reviewed and read:: When any resident experiences a fall the facility will: Complete neuro (logical) checks for any unwitnessed fall or witnessed fall where resident hits their head: Initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 did not ensure that the residents environment remained free of accident hazards or received adequate supervision to prevent accidents for 2 (R67, R71) of 5 residents reviewed for falls. R67 did not have interventions in place that were initiated on 12/29/2022 after a fall. R67's bed was not pushed up against the wall to prevent R67 from slipping out of bed. R71 had a witnessed fall on 10/4/2022. The At Risk for Falls Care Plan was revised on 10/4/2022 with the intervention staff were to walk R71 twice daily. The intervention did not specify which staff were responsible for the intervention. No documentation was found showing this intervention was being done and staff interviewed were not aware of this intervention. Findings: The facility policy entitled Comprehensive Care Plan revised on 9/23/2022 states: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident consistent with 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.