Huntington Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Electronic Medical Record (EMR) review and staff interview, the facility failed to update PASARR's when Resident #150 had a diagnosis of Post Traumatic Stress Disorder (PTSD) and Resident #54 had a new diagnoses of major depressive disorder and anxiety. This failed practice was true for two (2) of nine (9) residents reviewed for PASARR's. Resident identifiers: Resident #54, #150. Facility census: 181. Findings included:a) Resident #54On 04/07/26 at 10:20 AM a review of the EMR for Resident #54 found a PASARR dated 04/24/16 noted the resident would be able to be discharged in 3-6 months. Resident #54 currently resides at the facility. In addition, the diagnosis of Major Depressive Disorder was added on 07/11/16. Anxiety diagnosis was added on 02/28/19. Bipolar Disorder was added to the diagnoses on 05/12/20. No evidence was found of an updated PASARR.In an interview with admission Coordinator #36 on 04/08/26 at 1:21 PM, she stated that she had resubmitted the updated PASARRs but could provide no evidence…

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 record review and staff interviews, the facility failed to include diagnoses of Post-Traumatic Stress Syndrome (PTSD), Bipolar disorder, and Major Depressive Disorder and anxiety on the Pre-admission Screening and Resident Review PASARR. This deficient practice was found true for (3) three of (9) nine residents reviewed for PASARR accuracy during the Long-Term Care Survey Process. Resident identifiers: #6, #54, and #150. Facility Census: 181. a) Resident #54 On 04/07/26 at 10:20 AM a review of the EMR for Resident #54 found a PASARR dated 04/24/16 noted the resident would be able to be discharged in 3-6 months. Resident #54 is currently resides at the facility. In addition, on 07/11/16 the diagnosis of Major Depressive Disorder was added. Anxiety diagnosis was added on 02/28/19. Bipolar Disorder was added on 05/12/20 to the diagnoses. No evidence was found of an updated PASARR. In an interview with the admission Coordinator #36 on 04/08/26 at 1:21 PM, stated that she had resubmitted the updated PASARR'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, record review, and staff interview the facility failed to develop a resident-centered care plan for activities for Resident #16, and the use of side rails for Resident #13. This failed practice was found true for (2) two of 41 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #16, and #13. Facility Census:181. Findings Include: a) Resident #16 The initial observation on 04/06/26 at 2:50 PM, found Resident #16 lying in bed, hollering out. No stimulation was on in the room. A record review on 04/09/26 at 9:00 AM, revealed a diagnosis of Autism for Resident #16. Further record review revealed an initial activities assessment for Resident #16 dated 07/30/25, under section C, Number 6 comments reads as follows: Per former caregiver, resident enjoys being up and active even if she is unable to meaningfully participate. Staff will involve in group activities when resident is up to wheelchair, and provide with coloring materials and fidget toys for leisure stimulation . Will monitor for signs of satisfaction. 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 Electronic Medical Record (EMR) review and staff interview, the facility failed to ensure residents were given the opportunity to attend care plan conferences and failed to revise a care plan after a resident had all teeth extracted. This was true for two (2) of 41 residents reviewed for care plans. Resident identifiers: #54, # 48. Facility census: 181. Findings included: a) Resident #45 A review of the care plan for Resident #45, on 04/08/26 at 10:45 AM, found the following: Focus: Oral/dental: (Resident name) requires assistance with their oral and/or dental care. Has natural teeth in poor repair with obvious caries and missing teeth. Date initiated: 02/01/25. Revision on: 02/11/25. Goal: (Resident name) will be free from dental complications thru review period. Date initiated: 02/01/25. Revision on: 10/18/25. Target date: 04/06/26. An interview with the Care Plan/MDS Coordinator #46 on 04/08/26 at 10:45 AM confirmed the care plan had not been updated after the resident had all teeth extracted on 10/08/25. b) Resident #48 During an interview with Resident #48 at…

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 staff interviews, the facility failed to provide an activities program to meet the needs and interests of each resident. This failed practice was found true for (1) one of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier #16. Facility Census: 118. Findings Include:a) Resident #16The initial observation on 04/06/26 at 2:50 PM, found Resident #16 lying in bed, hollering out. No stimulation was on in the room.A record review on 04/09/26 at 9:00 AM, revealed a diagnosis of Autism for Resident #16.Further record review revealed an initial activities assessment for Resident #16 dated 07/30/25, under section C, Number 6 comments reads as follows: Per former caregiver, resident enjoys being up and active even if she is unable to meaningfully participate. Staff will involve in group activities when resident is up to wheelchair, and provide with coloring materials and fidget toys for leisure stimulation . Will monitor for signs of satisfaction.The last Quarterly Activity Assessment completed 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 record review, resident interview, and staff interview, the facility failed to provide care and services in accordance with professional standards of practice. For one (1) of five (5) residents reviewed for the care area of unnecessary medications, the facility failed to implement physician's orders for blood glucose monitoring and failed to administer medication as ordered. For one (1) of three (3) residents reviewed for the care area of pain management, the facility failed to provide medication for hemorrhoid pain relief. Resident Identifiers: #62 and #136. Facility Census: 181. Findings included: Findings include: a) Resident #136 During an interview on 04/08/26 at 3:45 PM, Resident #16 stated, My hemorrhoids have been hurting constantly for two weeks. They used to be infrequent but not anymore. Finally a young nurse spread'em and put some on there, but only once. I can't even eat hotcake. During an interview on 04/09/26 at 9:30 AM, The Director of Nursing (DON) stated, I will call the unit manager…

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 interview and resident interview, the facility failed to keep an accurate medical record in the area of blood pressure documentation for Resident #8. Findings Included:a) Resident #8 During an interview with Resident #8 on 04/06/26 at 1:26 PM, he reported having a fistula in his left arm. He stated no one ever tried to take his blood pressure in that arm. On 04/09/26, a review of resident's blood pressure summary since 01/01/26 show the following blood pressures documented to have been taken in the left arm in 2026: 3/7/26 122/68 l/arm Licensed Practical Nurse (LPN) #1873/16/26 127/77 l/arm LPN #823/20/26 124/66 l/arm Registered Nurse (RN) #744/3/26 112/62 l/arm RN #744/4/26 104/67 l/arm LPN #614/8/26 111/69 l/arm l/arm LPN #123 c)Review of Facility Performance Improvement Project dated 04/02/26. The plan To eliminate incidents related to improper blood pressure documentation on residents with limb restrictions. Licensed Practical Nurse #123 was educated on 04/06/26 and documented blood pressure in the wrong arm two (2) days later. d) An interview 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 observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to implement the correct transmission based precautions for a resident being treated for an active multidrug-resistant organism (MRDO). This was true for one (1) of three (3) residents reviewed for the care area of transmission based precautions. Resident Identifier: #182. Facility Census: 181. a) Resident #182 The facility's policy titled, Transmission-based Precautions, dated 02/01/22 and reviewed on 10/24/22, stated that contact precautions may be implemented for residents known or suspected to be infected with microorganisms transmissible by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Also, according to the policy, with contact precautions, staff must wear gloves and gowns when entering the room for all interactions with 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 and resident and staff interview, the facility failed to ensure call lights were within reach and accessible to Residents #166, 487, 184, 38. This was a random opportunity for discovery. Resident identifiers: 166, 487, 184, 38. Facility census: 184. Findings include: A) Resident #166 At approximately 2:25 PM on 3/17/2025, during an interview with Resident #166, she stated she was unable to ring her call light for help because she did not know where it was. Upon further inspection, Resident #166 ' s call light was found to be lying on the floor to the left side of her bed. At approximately 2:37 PM on 3/17/2025, the call light was confirmed to be in the floor and out of reach of Resident #166 by Licensed Practical Nurse (LPN) #75. B)Resident #487 At approximately 2:55 PM on 3/20/2025, during observation of the lunch meal pass, Resident #487 stated to the surveyor, I need to go to the bathroom but I can ' t find my button (call light). Upon further inspection, Resident #487 ' s call light was found to be on the floor, to the left side of her bed. At approximately…

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 Staff Interview, the facility failed to ensure the Resident and/or Power of Attorney (POA) was notified of a change in condition/order. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #7, #151, #169, #48, #8, #80, #97, #59, #34, #58, #111, #152, #124, #116, and #33. Facility Census: 184 Findings included: -The Facility's Policy and Procedure for Change in a Residents Condition stated, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status. a) Resident #7's Resident #7's order was revised on 03/19/25. Aspiration Precautions were removed from the resident's dietary order. b) Resident #151 Resident #151's order was revised on 03/19/25. Double portions of protein with lunch and dinner, Full upright position with PO, Alternate bites and drinks were removed from the resident's dietary order. c) Resident #169 Resident #169's order was revised on 03/19/25.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two (2) of 50 residents reviewed in the long-term care survey sample and one (1) of three (3) closed record reviews. Resident identifiers: #9, #21, and #183. Facility census: 184. Findings included: a) Resident #9 Review of Resident #9's medical records showed a weekly wound evaluation completed on 01/08/25. A suspected deep tissue injury to the left heel was noted. This was a new skin issue that had been present when the resident returned to the facility from the hospital that day. An order was entered to apply sureprep to the wound and monitor the skin surrounding the wound. Resident #9's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 01/10/25 documented that the resident had no unhealed pressure ulcers or injuries. On 03/20/25 at 4:13 PM, the Regional MDS Coordinator confirmed Resident #9's MDS with ARD 01/10/25 should have documented the resident had a…

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

Based on record review and staff interview, the facility failed to revise care plans for three (3) of 50 reisdents. Resident #31's care plan was not revised regarding safety checks. Resident #109 did not have a care plan revised with the discontinuation of dialysis and comfort care in place. Resident #67 did not have a care plane revision for the discontinuation of opiate. Resident #24 did not have a care plan for Enhanced-Barrier Precautions (EBP) and a multidrug resistant organism (MDRO). Resident identifiers: #31, #109, #67. Facility Census: 184. Findings include: a) Resident #31 On 03/24/24 at 1:00 PM, a record review was completed for Resident #31. The review found the resident had a physician's order dated 09/05/24 for safety checks every 30 minutes document on paper. The safety checks were added for a history of multiple falls and family request. The care plan listed a focus area of (Name of Resident) has experienced an actual fall, continues to be at risk for falls related to weakness, impaired mobility and left femur fracture, muscle wasting, Atrial Fibrillation,…

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 d) Resident #179 On 03/17/25 at 3:28 PM, Resident #179 was interviewed in her room. She was tearful. She stated she was supposed to have a shower today, but she hadn't had one yet. She stated she wanted her hair washed today. Her hair looked greasy. Review of the facility's shower schedule showed the resident was scheduled to receive showers on Mondays and Thursdays. Resident #179's bathing/showering task report for the last 30 days was reviewed on 03/18/25. The only shower documented in the last 30 days was on 03/17/25. The resident was documented as receiving bed or towel baths on 02/19/25, 02/20/25, 02/21/25, 02/22/25, and 02/24/25. The resident was out of the facility from 02/24/25 through 03/07/25. The resident was documented as receiving bed or towel baths on 03/07/25, 03/08/25, 03/09/25, 03/10/25, 03/13/25, 03/15/25, and 03/16/25. Resident #179's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/06/25 gave the resident's Brief Interview for Mental Status (BIMS) score as 9,…

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 record review and staff interview, the facility failed to follow physician's orders for Resident #144's arm restrictions, the amount of assistance needed for transfers for Resident #31, Resident #31's safety checks, and Resident #7's aspiration precautions. This was true for three (3) of 50 residents reviewed during the survey process. Resident Identifiers: #144, #31 and #7. Facility Census: 184. Findings Include: a) Resident #144 On 03/19/25 at 9:00 AM, a record review was completed for Resident #144. The review found a physician's order dated 11/19/24 stating, Dialysis: No BP (blood pressure) or lab draw in right arm due to permacath every shift for ESRD (end stage renal disease). The review, for 03/2025, found multiple dates and times the blood pressure was taken in the right arm. The following are the dates and times: --03/18/25 at 9:19 AM --03/17/25 at 8:51 PM --03/17/25 at 5:18 AM --03/16/25 at 8:51 PM --03/14/25 at 5:25 AM --03/12/25 at 8:04 PM --03/08/25 at 8:45 PM --03/07/25 at 8:27 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 observation and resident and staff interview, the facility failed to ensure proper portions were served to residents during mealtimes. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 184. Findings include: a) Resident #101 During an interview on 03/17/25 at 12:01 PM, Resident #101 stated the food portions at the facility were too small. At approximately 12:45 PM on 03/19/25, an observation was conducted during lunch service in the facility kitchen. The diet spreadsheet for the meal called for the following portion sizes to be served, six (6) ounces of homestyle lasagna; one (1) dinner roll; four (4) ounces of Italian green beans; four (4) ounces of chocolate pudding; four (4) ounces of milk; eight (8) ounces of coffee or hot tea. During service, Dietary Aide (DA) #176 was observed serving regular lasagna with a number ten scoop, ground lasagna with a number ten scoop, ground chicken (main dish for the alternate meal) with a number ten scoop. Size ten scoops will serve approximately three…

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 resident and staff interview, the facility failed to provide appetizing and palatable meals to residents of the facility. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #116, #166. Facility census: 184 Findings include: a) At approximately 1:05 PM on 03/17/25, during an interview with Resident #116, the resident stated the food at the facility was awful. At approximately 2:31 PM on 3/17/2025, during an interview with Resident #166, the resident stated The food is horrible. It tastes awful and it's cold. At approximately 12:00 PM on 3/19/2025, the dietary department presented surveyors with test trays. The meal was tested by five (5) of five (5) surveyors in the facility at the time. The meal consisted of chicken strips, broccoli, and parsley noodles. Upon examination of the meal, the broccoli appeared gray in color as opposed to green. Upon tasting the broccoli, it was non-cohesive and formed a mush-type substance when picked up with a fork…

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, record review, and staff interview, the facility failed to ensure meals were delivered in a timely manner and failed to ensure snacks were delivered to residents, as ordered. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #65, #135, #76, #134, #1, #155, #149, #87, #54, #30, #19. Findings include: a) Mealtimes Upon entrance to the facility on 3/17/2025, the survey team was provided with a document titled Meal Service and Tray Cart Delivery Times. According to the schedule, lunch service was as follows: Third Floor- 11:30 AM to 11:50 AM Third Floor Assists- 11:50 AM to 11:55 AM Fourth Floor- 11:55 AM to 12:10 PM West 12:10 PM to 12:25 PM South 12:25 PM to 12:40 PM Fourth Floor Assists 12:40 PM to 12:55 PM Parkway 12:55 PM to 1:10 PM During an interview conducted with Dietary Aide (DA) #147 at approximately 11:00 AM on 3/17/2025, he was asked when the kitchen started meal service, he stated, We try to start between 12:15 PM and 12:30 PM if we…

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 staff interview, the facility failed to ensure complete temperature logs for food, the chemical test log for the three (3) compartment sink, and to reheat resident food to appropriate temperatures before consumption. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Findings include: a) Temperature log On 3/20/2025, temperature logs from the dietary department were reviewed. During the review, it was determined a number of logs in the range of 03/01/25 through 03/19/25 had not been completed. 3/4/2025- None completed 3/5/2025- Dinner not completed 3/6/2025- Dinner not completed 3/7/2025- Breakfast and lunch not completed 3/8/2025- Breakfast and lunch not completed 3/9/2025- None completed 3/10/2025- None completed 3/11/2025- None completed 3/12/2025-Dinner not completed 3/13/2025- Dinner not completed 3/16/2025- Dinner not completed 3/17/2025- Dinner not completed 3/19/2025- Lunch and dinner not completed These were confirmed as incomplete in an interview with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure an accurate and complete record for five (5) of 50 residents. For Resident #144 the diagnosis for a medication was incorrect. The date of transfer and diagnosis of a medication for Resident #24 was incourrect. Resident #14's choice for medically assisted nutrition was incorrect and Resident #487's code status and documentation of a fracture for Resident #69 were incorrect. Resident Identifiers: #144, #24, #14 #487 and #69. Facility Census: 184. FindingsiInclude: a) Resident #144 On [DATE] at 12:15 PM, a record review was completed for Resident #144. The review found a physician's order for Eliquis 5mg (milligram) by mouth two times daily for essential (primary) hypertension. However, the primary use for Eliquis, a blood thinner, is prevention and/or treatment of blood clots. The resident had a diagnosis of thrombosis and embolism. On [DATE] at 2:00 PM, Registered Nurse (RN) #44 confirmed the diagnosis for the Eliquis was incorrect. 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.

Based on observation and resident and staff interview, the facility failed to maintain proper infection control standards by failing to complete hand hygiene with residents before meals. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #97, #106. Facility census: 184. Findings include: a) At approximately 12:45 PM on 3/20/2025, the survey team was present in the 300 hallway to observe lunch. At approximately 1:20 PM, lunch service started on the hallway. From approximately 12:45 PM through the time service began, no hand hygiene was seen being performed for the residents who wished to receive it before their meals were delivered. Facility staff had a bottle of hand sanitizer sitting on top of the delivery carts; however, it was being used for staff hand hygiene. Lunch service was completed and no residents on the hallway were observed by the survey team receiving hand hygiene. At approximately 1:29 PM on 3/20/2025, an interview was conducted with Resident #106…

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 Record Review, the facility failed to provide a home-like dining environment and to serve residents in the Third Floor Assisted Dining Room at the same time in order. This was a random opportunity for discovery. This failed practice had the potenital to affect more than a limited number of residents. Resident Identifer: #7. Facility Census: 184. Findings included: a) The facility's Dining Experience policy and procedure stated, Design the meal serving tray delivery to ensure residents seated at the same table are served at the same time, similar to a restaurant with table service. b) On 03/19/25 at 12:52 PM, the surveyor observed the Third Floor Assisted Dining Room. Residents were not served at the same table at the same time or in order. Resident #7 waited twelve (12) minutes after all the other residents in the dining room were served to receive the lunch tray.

Based upon Record Review and Staff Interview, the facility failed to ensure a resident with capacity was given the right to participate in the development and sign advance directives and a signature was not obtained in a timely manner by the Resident's Health Care Surrogate. This was true for two (2) of fifty (50) advanced directives reviewed. Resident identifiers: #487 and #75. Facility Census: 184. Findings included: a) Resident #487 The resident's Portable Orders for Scope of Treatment (POST) form was reviewed. The capacitated resident's POST form was signed by the Power of Attorney and not the capacitated resident. This was confirmed by Corporate Registered Nurse #223 on 03/18/25 at 5:00 PM. b) Resident #75 On 03/20/25 at 10:06 AM , the State Surveyor interviewed Social Worker #1 concerning Resident #75's Advanced Directive/POST form being signed in a timely manner. Social Worker #1 confirmed there were no documented attempts to obtain the Power of Attorney's signature. Resident #75's Power of Attorney had given verbal consent on 09/18/23.

Based on record review and staff interview, the facility failed to ensure a complete and accurate Preadmission Screening and Resident Review (PASRR) had been completed for one (1) of four (4) residents reviewed for the care area of PASRR. Resident identifier: #179. Facility census: 184. Findings included: a) Resident #179 Review of the facility's policy titled, Antipsychotic Medication Use, with no approval or implementation date given, stated that Preadmission Screening and Resident Review (PASRR) would be reviewed for residents transferred from a hospital who were already receiving antipsychotic medications. Review of Resident #179's medical record showed a PASRR completed on 02/11/25, before the resident's admission to the facility. The PASRR documented the resident had no major mental illness or suspected mental illness. Review of Resident #179's medical records showed she had a diagnosis of schizophrenia. She had been admitted to the facility from the hospital. The hospital recommended the facility continued the antipsychotic medication Loxapine, which the resident had been…

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

Based on record review and staff interview, the facility failed to develop and implement care plans This was true for two (2) of five (5) residents reviewed. Resident identifiers: #144 and #24. Facility Census: 184. Findings Include: a) Resident #144 On 03/18/25 at 1:00 PM, a record review was completed for Resident #144. The review found the care plan focus area of (Name of Resident) may decline to attend dialysis, at times. She may refuse hygiene care, including showers and bed baths. May report contradictory information at time (Typed as written.) These areas had no interventions or goals noted. In addition, the focus area of risk for falls had an intervention stating, no description provided. (Typed as written.) Lastly, a focus area of risk for pain, listed an intervention of administer medication as ordered. (Typed as written.) The resident did not currently have a physician's order for any type of pain medication. On 03/19/25 at 10:04 AM, Registered Nurse (RN) #44 confirmed the errors on the care plan. RN #44 stated, We have some errors .we will get these fixed. b) 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 record review and staff interview, the facility failed to document the amount of nutritional supplement consumed for one (1) of 10 residents reviewed for the care area of nutrition. Resident Identifier: #14. Facility census: 184. Findings included: a) Resident #14 Review of Resident #14's physician's orders showed an order written on 02/22/24 for Fortified pudding three times a day for weight loss. The resident's Medication Administration Record (MAR) showed the resident received fortified pudding three (3) times a day. However, the amount eaten by the resident was not recorded. On 03/20/25 at 10:38 AM, the Director of Nursing confirmed Resident #14's consumption of fortified pudding was not recorded. No further information was provided through the completion of the survey.

Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate during the facility task of Medication Administration was less than 5%. The medication error rate was 7%. Resident identifier: #17. Facility Census: 184. Findings included: a) Resident #17 On 03/19/25 at 7:10 AM, Licensed Practical Nurse (LPN) #76 was observed administering morning medications to Resident #17. The medications were in blister packaging, where tablets were individually pushed through the sealed foil into the medication administration cup by LPN #76. LPN #76 dispensed a buspirone 10 mg tablet from the blister package into the medication administration cup. She placed the buspirone blister package back into the medication cart drawer. She pulled the buspirone blister package back out of the medication cart and pushed another buspirone 10 mg from the blister packaging into the medication administration cup. The other medications LPN #76 dispensed from blister packets into the medication administration cup for Resident #17 were amlodipine, baclofen,…

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, Policy and Procedure and Staff Interview, the facility failed to provide a resident with adaptive equipment per order. This was a random opportunity for discovery. Resident identifier: #146. Facility Census: 184. Findings included: a) Resident #146 Resident #146 was ordered a divided plate on 11/28/23. On 03/19/2025 at 01:02 PM, Resident #146 was served the lunch meal on a regular plate. Tray card for a divided plate was reviewed and confirmed with Licensed Practical Nurse (LPN) #76 on 03/19/25 at 01:02 PM. Resident #146's care plan stated, Diet as ordered-built up utensils, divided plate. Policy and Procedure reviewed stated, Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them.

Based on observations and staff interviews the facility failed to post the correct menus. The lunch menus posted on the third and fourth floors of the initial tour for the complaint survey were incorrect. This deficient practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 173. Findings included: a) Menu postings Observations on 09/11/23 at 10:45 at 10:45 AM, revealed the lunch menus posted on the third and fourth floor were incorrect. The menu had hamburgers with tater tots as the entree. Observations during the kitchen tour on 09/11/23 at 11:50 AM, found the steam table had marinated chicken thighs, sugar snap peas, oven roasted potatoes as the entree. In an interview with the Certified Dietary Manager (CDM) on 09/11/23 at 11:55 AM, the CDM verified the wrong menus had been posted on the third and fourth floors.

Based on observations and staff interview the facility failed to prepare and serve food in accordance with professional standards for food service safety. During the tour of the kitchen for the complaint survey it was discovered a dietary aide was not wearing a beard guard. The deficient practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 173. Findings included: a) Kitchen tour During the kitchen tour on 09/12/23 at 11:50 AM, it was discovered a dietary aide (DA) #12 had no beard guard on. Also, a review of the temperature log book indicated the last meal to have temperatures recorded was for the dinner meal on 09/07/23. An interview with the Certified Dietary Manager (CDM) on 09/12/23 at 11:55 AM, verified DA #12 was not wearing a beard guard and no temperatures had been recorded after the dinner meal on 09/07/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, resident interview and staff interview, the facility failed to maintain an effective pest control program so the facility would remain free of pests and rodents. These were random opportunities for discovery. This faileed practice had the potential to affect all residents residing in the facility. Facility census: 185. Findings included: a) Pest Control Documentation On 08/02/23 at 11:15 AM, throughout the initial interviews with residents, multiple statements were made regarding seeing roaches and mice throughout the facility. On 08/03/23 at 10:00 AM, a grievance dated 06/08/23 was reviewed with a concern mentioning pests (mice) in the facility. The follow-up action dated 08/01/23 stated that pest control is on going. The pest control invoices were reviewed on 08/03/23 at 2:00 PM. The invoice dated 05/02/23 identified multiple open conditions, including a door sweep which was noted to be inadequate at the 3rd (third) floor courtyard doors which aren't rodent proof. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, staff interview, and Resident Council meeting, the facility failed to invite residents to care plan meetings, and to revise a care plan. This was true for five (5) out of 41 residents reviewed during the long-term survey process. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #163, #61, #22, #185, and #1. Facility Census: 185. Findings Included: a) Resident #163 During the Resident Council meeting on 08/01/23 at 3:18 PM, Resident #163 said she has never been asked to attend a care plan meeting regarding her care. Resident #163 was admitted to the facility on [DATE]. Resident #163 has capacity. Notes in chart found there were two (2) care conference notes on 04/11/23 and 05/30/23. These notes stated, care conference help on this date. All care plans were reviewed, goals appropriate and will proceed. Responsible party invited and did not attend. On 08/01/23 at 4:35 PM, the Administrator and Director of Nursing (DON) were…

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

Based on observation, record review, resident interview, staff interview, and facility policy review, the facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for four (4) of eight (8) residents reviewed for ADL care. This failed practice had the potential affect more than a limited number of residents. Resident identifiers: #58, #91, #87, and #1. Facility census 185. Findings included: a) Resident #58 During an interview on 07/31/23 at 12:12 PM, Resident #58 said she does not get showers most of the time she has to wash off in a pan of water. Resident #58 had a white cap on her head that looked like a shower cap unable to see if her hair was clean or not. A review of orders from the Attending Physician found the order below: Residents receive a bed bath five (5) times weekly and a shower two (2) times a weekly on Tuesday and Friday. If a resident refuses a bed bath or shower, a progress note must be completed. A review of the facility form called the POC Response History, 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 and staff interview, the facility failed to provide meals at the scheduled time to ensure no more than 14 hours were between the evening and the morning meal and to ensure resident evening scheduled snacks were provided. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census: 185. Findings included: a) Scheduled Snacks During the initial tour of the fourth-floor pantry on 07/31/23 at 12:15 PM seven (7) Scheduled Evening snacks were found dated 07/30/23. During an interview on 07/31/23 at 12:17 AM, the Dietary Manager confirmed the scheduled evening snacks should have been delivered to the Residents. b) Dining Observation A dining observation on 08/02/23 at 11:13 AM found the meal delivery cart was not being delivered as the posted delivery schedule. The food carts arrived on the halls an hour late. The third floor Scheduled Delivery time is 8:30 AM - 8:45 AM, the arrival of the cart was 10:08 AM. The last evening cart for the 3rd floor was between 6:45 PM - 7:00 PM . These residents went more than 14 hours…

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

Based on observation and staff interview, the facility failed to complete the refrigerator temperature log on the refrigerator on the third floor and fourth floor pantries and completed the PM shift temperature on the reach in freezer prior to the shift. This has the potential to affect all Residents that get their nutrition from the kitchen and pantries. Facility census: 185. Findings included: a) Kitchen During the initial kitchen tour with the Dietary Manager on 07/31/23 at 11:21 AM an observation of the reach-in temperature log found that the 07/31/21 the evening temperature was completed on the log at this time. A continued tour on 07/31/23 at 12:04 PM on the third-floor pantry found the temperature log was not completed 12 times in the free-standing refrigerator for the month of July 2023. A continued tour on 07/31/23 at 12:17 PM on the fourth- floor pantry found the temperature log was not completed 23 times in the free-standing refrigerator in the month of July 2023. On 07/31/23 during tour the Dietary Manager (DM) verified that the pantry refrigerator temperatures should…

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 staff interview, the facility failed to store garbage and refuse in a proper manner to prevent rodents and pests. This has the potential to affect more than a limited number of residents that reside in the facility. Facility census: 185. Findings included: a) Dumpsters An observation of two (2) dumpsters on 08/01/23 at 11:26 AM found one (1) dumpster did not have a lid and both dumpsters were left open. During an interview on 08/01/23 the Maintenance Director verified the dumpsters should be closed and have lids to prevent rodents. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to maintain an accurate and complete medical records. This was true for four (4) of 41 medical records reviewed. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #162, #66, #185, and #84. Facility census: 185. Findings included: a) Resident #162 A review of Resident #162's care plan which had the following focus: decisions regarding suggested or recommended interventions and has specific preferences related to: POST: Full Code, .prefers to receive haircuts from the facility beautician as needed/requested. Prefers to have facial hair/beard, declines assistance with shaving. (Resident's name) has sexual relationships with female staff. He hugs and kisses female residents also. Date Initiated: 12/28/22. Revision on: 08/01/23. An interview with the Director of Nursing (DON) on 08/01/23 at 10:00 AM confirmed the above-mentioned statement that the resident has sexual relationships with…

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 staff interview, the facility failed to ensure residents were provided care in a dignified manner for one (1) of two (2) residents reviewed for the care area of dignity. Resident #84 was assisted with meals by staff who stood over the resident while assisting during the meal. This failed practice had the potential to affect a limited number of residents. Resident identifier: Resident #94. Facility census: 185. Findings included: a) Resident #94 An observation, on 08/01/23 at 1:19 PM, revealed Nursing Assistant (NA) #99 was standing in front of Resident #94 while assisting with the noon meal. NA #99 was assisting with bites of food and wiping the resident's mouth while standing up. An interview with NA #99, at 08/01/23 at 1:19 PM, confirmed she was standing over the resident while assisting the resident to eat the noon meal. When questioned, NA #99 stated I forgot, it did not pop in my head to sit down and I knew to do that. An interview with the Administrator, on 08/01/23 at 1:40 PM, confirmed it was facility policy for staff to seat themselves to assist…

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 medical records and staff interview, the facility failed to complete a Minimum Data Set (MDS) in the area of skin conditions for one (1) of one (1) residents reviewed for skin conditions. This failed practice had the potential to affect a limited number of residents. Resident identifier: #60. Facility census: 185. Findings included: a) Resident #600 A review of Resident #60's medical records showed the resident had a blood-filled blister on her left ankle caused by a walking boot on her left ankle due to a fracture of the left lower leg (tibia and fibula). This blister was noted on 05/19/23. A review of Resident #60's MDS with an Assessment Reference Date (ARD) of 05/29/23, under Section S indicated the resident had no pressure ulcers. According to the National Pressure Ulcer Advisory Panel's (NPUAP) a Medical Device Related Pressure Ulcer/Injury: Medical device related PU/PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be…

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

Based on record review and staff interview, the facility failed to ensure an accurate discharge Minimum Data Set (MDS) assessment for one (1) of five (5) closed records reviewed during the long-term care survey. Resident identifier: #182. Facility census: 185. Findings included: a) Resident #182 A review of Resident #182's medical records showed the resident was discharged to the community on 06/15/23. Per the resident's choice, he was discharged to a homeless shelter, accompanied by his brother. The discharge Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 06/15/23 indicated the resident was discharged to an acute care hospital. During an interview on 08/01/23 at 4:15 PM, the MDS Coordinator #94 confirmed Resident #182's MDS assessment with ARD 06/15/23 was incorrect. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for two (2) of three (3) residents reviewed for the category of Preadmission Screening and Resident Review (PASARR), during the long-term care survey. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #53 and #1. Facility census: 185. Findings included: a) Resident #53 On 08/02/23, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 08/03/22, indicated no Level II was needed. Section lll #30 MI/MR Assessment indicated None. A continued record also revealed the resident received a psychiatric diagnosis of bipolar disorder on the diagnosis listed on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed. On 08/02/23 at 12:32 PM, an interview with admission Director and Social Work Director confirmed…

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 staff interview, the facility failed to ensure a baseline care plan was completed for one (1) of one (1) newly admitted residents reviewed. The facility failed to complete a baseline care plan for Resident #235 for the area of Activities of Daily Living (ADLs). Resident identifier: Resident #235. Facility census: 185. Findings included: a) Resident #235 A review of the baseline care plan, dated 07/26/23, showed a focus area noting Resident #235 had been identified to have an Activities of Daily (ADL) self-care performance deficit as evidenced by (the sentence was left blank and not completed to provide specific limitations ). The goal for this focus area of ADL deficit noted The resident will improve current level of function in (SPECIFY ADLS) through the review date. Resident will be able to: (SPECIFY), however, there was no evidence the care plan had been completed to reflect a specific resident centered problem or goal. Additionally, the care plan interventions did not indicate how many staff members were required to assist the resident or the frequency…

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 staff interview, the facility failed to develop a person-centered care plan. This was true for three (3) of 41 residents reviewed for care plans. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #58, #163, and #60. Facility census 185. Findings included: a) Resident # 58 During an interview on 07/31/23 at 12:12 PM, Resident #58 stated that she does not get showers most of the time. I have to wash off in a pan of water. A review of the care plan for Resident #58 found the care plan did not include the following: * What Resident #58 preferred showers or Bed baths. *When Resident #58 would prefer to have shower or bed bath in the AM or PM. *How often Resident #58 would like to have showers and/or bed baths. During an interview on 08/01/23 at 3:12 PM with Director of Nursing (DON) agreed the care plan was not person centered. b) Resident #162 Review of Resident #162's comprehensive care plan for behavioral/emotional and communications were incomplete. Care plan as follows: --Focus: The resident has impaired…

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 medical record review and staff interview, the facility failed to assess pressure ulcers when first identified to receive appropriate care and treatment for one (1) of three (3) residents reviewed for pressure ulcers. This failed practice had the potential to affect a limited number of residents. Resident identifier: #60 Facility census: 185. Findings included: a) Resident #60 A review of Resident #60's medical records showed the resident had a blood-filled blister on left ankle caused by a walking boot on the left ankle due to a fracture of the left lower leg (tibia and fibula). The blister was noted on 05/19/23. A review of the skin and wound evaluation completed on 05/19/23 at 6:01 AM by Licensed Practical Nurse (LPN) #60 marked this area as a diabetic ulcer. According to the National Pressure Ulcer Advisory Panel's (NPUAP) a Medical Device Related Pressure Ulcer/Injury: Medical device related PU/PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape 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, resident interview and staff interview, the facility failed to ensure resident environment remains as free of accident hazards as is possible. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifiers: Resident # 58. Facility census 185. Findings included: a) Resident #58 During an interview with Resident #58 on 07/31/23 at 12:21 PM, an observation found a white bottle of prescription medication sitting on the shelf over the sink in the room of Resident # 58 . Resident # 58 said it was from when she went to the hospital. Wrote on the white bottle was as written below: CPO-Aquaphor-Bacitracin-Nystatin Ointment. In Red it had warning EXTERNAL USE ONLY On 07/31/23 at 12:29 PM, Licensed Practical Nurse (LPN) #43 witnessed the medication over the sink and removed the medication and said it should not have been in there. .