Cedar Ridge Center

Based on record review and staff interview the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health. This was true for Two (2) of Two (2) residents reviewed related to foot health. Resident Identifiers: Resident #27 and #22. Facility Census: 115. Findings include: a) Resident #27 06/16/2026 8:56 AM Interview with Resident #27. He stated I need to see a podiatrist. His feet look bad. 06/17/26 9:31 AM I asked the DON to go and speak to Resident #27 with me and for her to look as his feet. After speaking to Resident #27 and looking at his feet, she agreed that the facility is not following the Physicians orders, or the care plan for Residents #27 Activities of Daily Living (ADL) care of his feet. She stated I will get him an appointment scheduled with a podiatrist today. Resident #27 has a physician order for: Podiatry obtain consult as needed / indicated and treatment for patient for health and comfort. Resident #27 care plan states: Focus: Resident requires assistance / is dependent for ADL care. Date Initiated: 07/18/25…

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 observation, record review and staff interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration each resident's preferences and physician's orders. Resident identifier: #22. Facility census: 115 Findings include: a) Resident #22 On 06/16/26 at 1:13 PM the south short meal cart arrived for lunch, and at 1:15 PM, Resident #22's meal tray was served without the additional sandwich and additional serving of fruit per the physician's orders dated 05/19/26. Resident #22's meal tray was served without the additional sandwich and additional serving of fruit per the physician's orders dated 05/19/26. This order was put in place due to Resident #22 having significant weight loss. Resident #22 was admitted on [DATE] at 106 pounds. Her last documented weight was on 06/10/26 and she weighed 86.2 pounds. She had lost a total of 19.8 pounds, which is 18.7% of her total body 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and record review the facility failed to ensure Resident #46 received ongoing opportunities to participate in meaningful activities consistent with her interests, and preferences. Specifically, following a significant change in condition after a fall resulting in multiple fractures, the facility failed to revise the resident's activity care plan and failed to provide consistent, individualized activity interventions. This resulted in a decline in activity participation and social isolations. This failed practice was found true for (1) one of (1) one residents reviewed for quality of life during the complaint survey. Resident identifier #46. Facility Census 113.a) Record review Resident #46A record review on 03/17/26 at 9:30 AM, revealed that Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur:…

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 a record review and staff interviews, it was determined that the facility failed to provide a 30-day discharge notice to a resident prior to their discharge. This failed practice had the potential to affect a minimal number of residents within the long-term care facility. Resident identifier: #98 Facility Census 113. Findings include:On 03/10/26 the State Agency received a complaint indicating Resident #98 was being discharged to a hotel on this date. The complainant indicated the facility told the resident they would pay for the first 28 days but after that the resident was on his own. The complainant indicated the resident did not have any income and was not sure how he would eat or get his medications. Record review completed on 03/18/26 revealed the following:A Social Service note dated 03/06/26 documented discharge planning discussions and a referral to the Take Me Home program at the resident's request.An assessment note dated 03/10/26 indicated discharge plan documentation was completed.A Social…

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 update an activity care plan after Resident #46 had a significant change in her participation. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the complaint survey process. Resident identifier #46. Facility Census 113.Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction.Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. Osteopenia noted. During an interview on 03/18/26 at 11:40 AM, Resident #46 who has capacity and a Brief Interview for Mental Status (BIMS) of 15 stated, Nobody understands what this has done to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview the facility failed to provide a program of activities to meet the interest and needs of Resident #46 who has had a significant change in her activity participation. This failed practice was found true for (1) one of (1) one residents reviewed for activities during the complaint survey. Resident identifier #46. Facility Census: 113. Findings Include:a) Resident #46A record review on 03/17/26 at 9:30 AM, revealed that Resident #46 had a fall on 02/18/26 and was sent to a local emergency room for pain to her right and left legFurther record review of the Diagnostic Radiology reports from the hospital showed the following:Left Femur: Anterior apex angulated fracture of the distal femur diametaphyseal fracture with impaction.Right Knee: Impaction and comminuted anterior apex angulated fracture distal fifth metaphysis present. Osteopenia noted. During an interview on 03/18/26 at 11:40 AM, Resident #46 who has capacity and a Brief Interview for Mental…

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 manage pain in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of pain. Resident Identifier: #14. Facility census: 117. Findings included:a) Resident #14 The facility's policy titled Pain Management with effective date 01/01/04 and revision date 03/24/25 stated that reasons for as needed (PRN) pain medications would be documented. Review of Resident #14's physician's orders showed the resident was receiving the following scheduled pain medications: -Morphine sulfate extended relief tablet, 10 mg, three (3) times a day for pain, ordered 01/18/26-Morphine sulfate extended relief tablet, 60 mg, two (2) tablets, three (3) times a day for pain, ordered 01/31/26 Resident #14 also had an order to document the pain level and non-pharmaceutical interventions for pain every shift. Pain was assessed on a score of 0-10, with 0 being no pain and 10 being the highest pain imaginable. Resident #14 was also ordered the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and food tray temperatures, the facility failed to serve food to residents that was palatable and at an appetizing temperature. Based on resident interview and staff interview, the facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice was true for one (1) of one (1) hallways tested for food tray temperatures throughout the complaint survey process. Resident #35. Facility census: 117.Findings include: a) The facility was not taking and documenting all food temperatures prior to sending the food to the residents. The facility was also sending cold food out above the FDA Food Code temperature of 41 degrees Fahrenheit. The Healthcare Services Group policy 016 titled Food Preparation shows the following: All foods are prepared in accordance with the FDA Food Code. Cold foods at 41 degrees F or below and hot foods at 135 degrees F or above before it leaves the kitchen.This surveyor asked for a copy of the service line checklist dated 02/01/2026 -…

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, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than an isolated number of residents. Facility census: 117. Findings include: a) The Healthcare Services Group (HCSG) policy 019 titled Food storage: Cold Foods shows the following: All Time / Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. All foods will be stored wrapped or in a covered container, labeled and dated, and arranged in a manner to prevent cross contamination. The HCSG policy 027 titled Equipment shows the following: All foodservice equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. All staff members…

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 provide accurate and complete medical records for four (4) of 24 residents reviewed in the long-term care survey sample. Transfer assessments were not accurate for Residents #78 and #7. Tube feeding documentation was not accurate for Resident #47. Additionally, the activities assessment for Resident #21 was not completed by a qualified staff member. Resident Identifiers: #78, #7,#47, and #21. Facility census: 117.Findings included:a) Resident #78 On 02/18/26 at 3:30 PM, a review was completed for Resident #78. The review found the resident had been transferred to an acute care facility on 12/26/25. However, the transfer form had the incorrect date of 10/31/25. On 02/19/26 at 10:00 AM, the Corporate Registered Nurse (RN) #156 confirmed the transfer form had the incorrect date noted. b) Resident #7 On 02/18/26 at 4:30 PM, a review was completed for Resident #7. The review found the resident had been transferred to an acute care facility on…

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

Based on record review and staff interview, the facility failed to complete the quarterly assessments for restraint usage for Resident #6. This was true for one (1) of one (1) residents reviewed under the care area of restraints. Resident Identifier: #6. Facility Census: 117. Findings Include: a) Resident #6 On 02/18/26 at 8:30 AM, a record review was completed for Resident #6. The review found the following physician's order dated 04/22/25, Restraint: Positioning device/belt to w/c (wheelchair) while up in w/c for dx (diagnosis) of Cerebral Palsy and involuntary movements of core/ trunk area. Release device/belt every 2 (two) hours for repositioning every 2 (two) hours for seat belt to chair. Also, the review found the last restraint evaluation/reduction was completed on 05/29/25. The evaluation/reducation should be completed quarterly. On 02/18/26 at 10:20 AM, the Administrator was notified and confirmed the evaluation was not completed quarterly. b) Policy On 02/18/26 at 9:45 AM, a review of the facility policy entitled, Restraints: Use of was completed. Under section 6, states,…

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 comprehensive care plan for one (1) of 24 residents reviewed in the long-term care survey sample. Resident identifiers: #3. Facility census: 117. Findings included: a) Resident #3 Review of Resident #3's medical records showed diagnoses of post-traumatic stress disorder (PTSD) and exposure to disaster, war and other hostilities were documented on 01/20/26. On 02/17/26, the following focus was initiated on the resident's comprehensive care plan: Resident reports past experience of trauma as evidenced by: Feeling upset when reminded of a stressful experience from the past related to PTSD. On 02/18/2026 at 11:27 AM, Corporate Nurse #156 confirmed Resident #3 had not been care planned for PTSD until 02/17/26. No further information was provided through the completion of the survey process.

Based on record review and staff interviews th facilty failed to revise care plans related to one (1) on one(1) activities and PEG tube length. This failed practive was found true for two (2) of 24 residents care plans reviewed during the Long Term Care Survey Process. Resident identifiers: #50 and #47. Facility Census: 117Findings include: a) Resident #50 On 02/16/26 at 11:27 AM a Review of the participation record for Resident #50 showed most activities Provided were one-on-one activities. further record review of Resident #50's care plan revealed nothing in the care plan for Resident #50 to receive one (1) on (1) activities. Record review completed on 02/17/26 Revealed the one (1) on one (1) list provided from Activity Director (AD) #14 showed the resident was on the one (1) on one (1) program list to receive one (1) on one (1) activities. During an Interview with AD #14 on 02/17/26 at 3:40 PM she confirmed the one-on-one activities were not in the resident's care plan. b) Resident #47 Review of Resident #47's physician's order showed an order written on 02/06/26 to check 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 record review, resident interview, and staff interview, the facility failed to follow a physician's order for oxygen settings for Resident #20. Facility census 117. a) Resident #20. Based on observation, interview, and record review, the facility failed to ensure services were provided in accordance with physician orders. Specifically, the facility failed to ensure oxygen was administered at the ordered rate. On 02/18/26 at 9:19 a.m., observation of Resident #20 revealed oxygen delivered via nasal cannula at 4 liters per minute. Record review of the physician's orders indicated an active order for oxygen at 2 liters per minute via nasal cannula. On 02/18/26 at 9:19 a.m., interview with Nurse #111 confirmed the oxygen was set at 4 liters per minute and verified the current physician order was for 2 liters per minute. An interview with the Director of Nursing (DON) indicated that any increase in oxygen flow rate would require documentation of a change in condition and updated physician orders. However, as of 9:40 a.m. on 02/18/26, review of the medical record did not reveal…

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 posted daily nurse staffing information was accurate for one (1) of 20 days reviewed, resulting in incorrect staffing and census information being displayed. Facility Census: 117Findings include:Review of the facility's nurse staffing posting on 02/18/26 for staffing dated 07/06/25 showed the posted Hours Per Patient Day (HPPD): 2.19 and the posted facility census: 109 residentsDuring surveyor review, the facility administrator provided verified staffing documentation and census reports showing actual HPPD for 07/06/25 was 2.58 and actual facility census for 07/06/25 was 105 residentsDuring an interview the discrepancies were reviewed with the facility administrator On 02/19/26 at 11:00 AM when the administrator confirmed the staffing posting contained incorrect HPPD and census information.

Based on observation and staff interview the facility failed to ensure the residents received the proper portion sizes. This failed practice has the potential to affect more than an isolated number of residents and was a random opportunity for discovery found during the completion of the dining observation pathway during the long-term care survey process. Resident #44 and #91. Facility Census: 117. Findings include: a) The Healthcare Services Group policy 004 titled Menus shows the following: Menus will be planned in advance to meet the nutritional needs of the residents / patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Menu Cycles will include standardized recipes. Menu cycles will include nutrient analysis to ensure that all clients nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academics, and the Dietary Guidelines for Americans, 2020 - 2025 edition. Menus will be served as written,…

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, and staff interview, the facility failed to ensure that the resident's received a therapeutic diet for a renal diet and the 2 gram sodium diet. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #42, #56, #80, #78, #132, # 90, #98, #105 and #117 . Facility census: 117.Findings include: a) 02/18/2026 12:15 PM A review of Healthcare Services Group (HCSG) policy 008 titled Therapeutic Diets revealed Therapeutic diet is defined as a diet ordered by a physician, or delegated registered licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of the therapeutic diet is to eliminate or decrease specific nutrients in the diet, or to increase specific nutrients in the diet. All nine (9) residents that were on a Renal diet and / or the 2 gram sodium diet, did not receive low sodium marinara meat sauce for the lunch meal on 02/28/2026, as per the recipe and diet guide used by the facility, The tray ticket also showed that they…

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 complete and accurate comprehensive care plan in the area of medication refusals. This deficient practice had the potential to affect one (1) of three (3) residents in the survey sample. Resident Identifier: #111. Facility Census: 110.Findings included:a) Resident #111Review of Resident #111's medication administration record (MAR) and progress notes showed the resident began refusing medications on 09/04/25, the day after admission to the facility. Medications refused included atorvastin for hyperlipidemia, dapagliflozin for diabetes, divalproex for depression, famotidine for gastroesophageal reflux disease, insulin for diabetes, losartan for hypertension, melatonin for sleeplessness, metformin for diabetes, metoprolol for hypertension, and trazodone for depression. The medication refusals were frequent. On 11/13/25, the following focus was written on Resident #111's comprehensive care plan, Resident/Patient is resistive to care related to: Alzheimer's Disease hx [history] of resisting care, refusing…

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 medical records. Psychiatric telemedicine notes contained an inaccurate history of present illness (HPI) for Resident #111. This was a random opportunity for discovery. Resident Identifier: #111. Facility Census: 110.Findings included:a) Resident #111 Review of Resident #111's medical records showed the resident was seen by psychiatric telemedicine services on [DATE], [DATE], and [DATE]. Each of the notes written during these sessions had the following paragraph for history of present illness (HPI): 92 -year-old widowed female with a hx [history] of dementia, depression, anxiety. She was initially admitted to [facility] on [DATE] after an acute hospital stay at [hospital name]. [Resident's name] ambulates without assistance. She has three children, one is deceased . Son, [name] is HCS [health care surrogate] and supportive. However, the resident's age, admission date, first name, and HCS's name were incorrect in this…

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 interviews, the facility failed to maintain an environment free of accident hazards for 1 out of 26 residents. Facility census 112. Scope and Severity D On 11/11/25 at approximately 11:07 p.m., observed a medicine cup with 1 pill in it located on the bedside table of resident #8. I then notified the Director of Nursing (DON) to come to the room and verify that there was a medication cup with 1 pill in it on the bedside table. The DON verified that the medication cup was on resident #8 bedside table. The DON and myself went and checked 26 residents (Rms 1-16) and there was only 1 out of 26 residents that had the medication cup with meds left at their bedside. The DON verified that medication pill pass was performed by employee # 81. The medication identified was a 1/2 tab of Senokot.On 11/11/25 at approximately 11:08 p.m., interview the DON verified that employee #81 did leave a medication cup with a 1/2 tablet of Senokot on the bedside table of resident #81. This deficiency was also again verified by the DON and acknowledged by the Administrator upon…

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 that narcotics in the facility were managed and controlled in a safe manner. This is true for eleven (11) of eleven (11) residents reviewed during the survey. All residents that receive pain medication in the facility have the potential to be affected. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur, however due to the facility identifying the missing medications and replacing them immediately for the Residents that remained in the facility no Residents were harmed by this incident. Resident Identifier: #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12. Facility Census: 112 Findings Include:a) Residents #11 and #12Resident #11On 10/15/25 at 9:10 AM, record review of a reportable facility incident revealed that on 06/28/25 when a staff member attempted to reorder Resident #11's Hydrocodone…

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 complete all Physicians orders for wound treatment. This was true for one (1) of three (3) residents reviewed during this investigation. Resident Identifier: #1 Facility Census: #112 Findings Include:a) Resident #1On 10/16/25 at 9:10 AM record review of Resident #1 orders and Treatment Administration Records (TAR) for August, September and October 2025 found missing documentation as shown below. All orders and TAR's were reviewed for the period of 08/01/25 - 10/31/25. None of the following Physician orders were completed on 10/09/25, 10/16/25, 10/21/25 or 10/22/25.Clean DTI (deep tissue injury) to left buttocks with wound cleaner, pat dry, apply skin prep to area and leave open to air every day shift.Clean left outer foot (amputation site) with wound cleaner, pat dry, apply Betadine and leave open to air every day shiftClean venous ulcer to left dorsum 1st digit (hallux) with wound cleaner, pat dry, apply Betadine and leave open to air every day…

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 and resident and staff interviews, the facility failed to deploy sufficient direct care staff to meet the needs of the resident population of the facility. This had the potential to affect all residents residing in the facility. Resident identifiers: #94, #58, #51, #85, #91, and #84. Facility census: 111. Findings include: a) Resident #94 On 04/13/25 at approximately 3:09 PM, an interview was conducted with Resident #94. Resident #94 stated the facility was very understaffed. Resident #94 said, They keep telling me they're hiring people, but no one ever stays. The ones that don't do their job, they keep because they can't keep other people, so they have no choice but to keep them. At approximately 9:05 PM on 4/14/25, the call light for Resident #94's room was observed ringing in the North Hall of the facility. At approximately 9:16 PM, Resident #94 was observed yelling Hello multiple times from inside his room, but did not receive an answer. During this time, Licensed Practical Nurse (LPN) #36 and Nurse Aide (NA) #21 were on the hallway. LPN #36 was passing…

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, staff interview and resident interview, the facility failed to ensure the residents' right to to receive mail on Saturdays was honored. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 111. Findings included: a) The facility's policy and procedure stated, The Recreation Director or designee will: .1.2 Ensure that mail is delivered to the person unopened or postmarked (for outgoing mail) within 24 hours, including Saturdays. b) On 04/14/25 at 02:05 PM during the Resident Council Meeting, the residents reported that mail was not delivered on Saturdays. c) On 04/15/25 at 10:13 AM, the Administrator confirmed mail was to be delivered on Saturdays. The Administrator stated, Mail was supposed to be delivered. She reported the two activities directors will begin working the weekends since they had recently had an assistant leave and there are two open positions in that department. The Administrator reported she will educate and begin an audit for the residents to receive mail timely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow administration directions for medications prescribed for the control of phosphorous levels for dialysis patients. This was true for 5 of 5 residents on dialysis. Resident Identifiers: Residents #33, #88, #94, #105 and #108. Facility census:111. Findings Include: a) Resident #33 Record review and interview on 04/13/25 at 2:35 PM revealed, Resident #33 is a [AGE] year-old female on hemodialysis diagnosed with the following conditions: Chronic systolic heart failure Chronic respiratory failure with hypoxia Type 2 diabetes mellitus with polyneuropathy End-stage renal disease on hemodialysis Dilated cardiomyopathy History of nicotine dependence Hypertension Morbid obesity Gastroesophageal reflux disease Anemia A review of the resident's medication orders on 04/15/25 at approximately 11:55 AM revealed Resident #33 was prescribed: Renvela Oral Tablet 800 MG (Sevelamer Carbonate). Give 3 tablets by mouth before meals for end stage renal…

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 each resident received the proper portion size of pork during the evening meal on 04/16/25. This failed practice has the potential to affect more than an isolated number of residents and was random opportunity for discovery found during the completion of the kitchen pathway during the long-term care survey process. Facility Census: 111. Findings Include: On 04/16/25 at 5:32 PM the surveyor was observing meal service from the steam table in the facility's kitchen. [NAME] #130 was serving the food from the steam table. She was observed using tongs to serve the pork. The Director of Operations (DOO) was asked how she was sure the pork she was serving was two ounces (OZ) she stated she should be using a 2 oz scoop and not tongs. She corrected the situation; however, the North Short Hall and the South Short Hall had already been served. A review of the menu found each resident should be served 2 ounces of pork.

Based on observation and staff interview the facility failed to ensure all residents received meals at regular times comparable to normal mealtimes in the community. The lunch meal on 06/04/25 was served 45 minutes late to 19 residents due to the facility running out of prepared food. This was true for Resident #95, #3, #68, #60, #90, #21, #29, #24, #56, #6, #61, #5, #41, #79, #38, #58, #36, #45, and #49. Facility Census: 101 Findings Include: a) An observation of the lunch meal began at 12:00 PM on 06/04/25 found the facility was serving ham, macaroni and cheese and beets as the main meal for the residents. At 1:10 PM [NAME] #1 stated, I ran out of food. I'm going to have to make more. The Corporate Director of Operations then began preparing and directing the staff on what to make to continue to the feed the remaining 18 residents. The Corporate Director of Operations, indicated they did not know what happened. They said they made more than the production sheet called for but was still short on servings. The final resident was served at 1:56 PM on 06/04/25 which was 46 minutes…

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

Based on observation and interview, the facility failed to ensure infection control procedures were adhered to in the residents' shower room. This failed practice had the potential for infection of a limited number of residents. This was true for one (1) of two (2) shower rooms inspected during the survey process. Facility Census: 111. Findings included: a) During an inspection of the male and female shower rooms, accompanied by Licensed Practical Nurse (LPN) #26 on 04/14/25 at approximately 1:20 PM, five bottles of unlabeled shampoo bottles were observed in the male shower room. LPN #26 confirmed the bottles of shampoo were not labeled with any resident names. On 04/14/25 at approximately 2:30 PM, the Director of Nursing (DON) confirmed all unlabeled shampoo bottles had been removed from the shower room.

Based on observation and resident interview, the facility failed to ensure Resident #94 was treated in a dignified manner, by allowing him to sit in a soiled brief for an extended period of time. This was a random opportunity for discovery. Resident Identifier: 94. Facility census: 111. Findings included: A) Observation At approximately 9:05 PM on 4/14/25, the call light for Resident #94's room was observed ringing in the North hall of the facility. At approximately 9:16 PM, Resident #94 was observed yelling Hello multiple times from inside his room, but did not receive an answer. During this time, Licensed Practical Nurse (LPN) #36 and Nurse Aide (NA) #21 were on the hallway. LPN #36 was passing medications and NA #21 was observed going back and forth between other resident rooms. At approximately 9:20 PM, NA #21 went to a soiled linen bin outside of Resident #94's room, at which time he yelled , Can I get an aide please? NA #21 placed items into the soiled linen bin, walked down the hallway, and did not acknowledge the resident. At approximately 9:23 PM NA #13 entered the Hallway…

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 resident interview, the facility failed to ensure the resident's right to voice a grievance to the facility without fear of reprisal for Resident #58. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #58. Facility Census: 111. Findings included: a) Policy Review The facility's policy and procedure stated, The patient/resident (hereinafter patient) has the right to voice grievances to the Center or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their Center stay. b) Resident Council A resident Council Meeting was held on 04/14/25 at 02:05 PM. The residents expressed you couldn't voice a concern at times without worrying that someone will get back at them. Several residents reported…

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, resident interview, staff interview and record review, the facility failed to ensure Resident #26 and Resident #70 were not neglected. Resident #70 asked for a snack for over 30 minutes she was eventually given a snack but it was the wrong consistency. The nurse aide then had to take it from her which upset the resident. The facility also failed to give Resident #26 his medication even though it was available in the pyxis machine. This was true for two (2) of seven (7) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #70 and #26. Facility Census: 111. Findings Included: a) Resident #26 An interview with Resident #26 on 04/13/25 at 2:44 PM found the Licensed Practical Nurse's (LPN) often let him run out of medication and he don't get it until it comes in from the pharmacy. When asked if knew what medications he runs out of he stated, I don't know the names of them, but I know one of them was for my restless leg syndrome. He indicated it…

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 complete a Minimum Data Set (MDS) for Resident #13 upon discharge from the facility. This was true for one (1) of thirty-eight (38) residents. This was a random opportunity for discovery and was true for Resident #13. Resident Identifier: #13. Facility Census : 111. Findings included: a) Resident #13 Resident #13's date of stay was from 10/23/24 through 11/11/24. The following Minimum Data Sets were completed for Medicare: Entry/MDS 3.0, Medicare 5 -Day/MDS 3.0 and admission -None PPS/MDS 3.0. A discharge MDS was not found during the record review. On 04/16/25 at 1:34 PM, the state surveyor interviewed MDS Coordinator #77. MDS Coordinator #77 confirmed a discharge MDS had not been completed. The MDS Coordinator stated, I did miss it. and We will fix it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure the care plan was implemented regarding pain management interventions for Resident #42, and regarding tracheostomy care for Resident #111. This was true for two (2) of 38 resident care plans reviewed during the survey process. Resident identifiers: #42, #111. Facility census: 111. Findings included: a) Resident #42 Resident #42 is receiving hospice services due to an end stage diagnosis of History of CVA (cerebrovascular accident). Resident #42 has an order for: Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 10 mg by mouth every two (2) hours as needed for pain/dyspnena. Give 0.50 ML. Hold for Sedation 0.50 ml, every two hours as needed for pain. At approximately 11:30 AM on 4/13/25, during observations in the North hall of the facility, Resident #42 was observed to be yelling out. Review of the resident's record on 4/13/25, it was noted some indicators for pain were yelling out, restlessness, tenseness. Resident #42…

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, residen 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 was true for two (2) of five (5) residents reviewed for ADL care.Resident Identifiers: #416 and #85. Facility Census: 111. Findings Included: a) Resident #416 On 04/16/25 at 11:28 AM, a review of Resident #416's toileting / toileting hygiene documentation in November 2024 found: --Day shift- three (3) entries of 97- Not applicable in 30 days. --Evening shift- three (3) entries of 97- Not applicable in 30 days. --Night shift- 12 entries of 97- Not applicable in only 30 days. During an Interview on 04/16/25 at 12:08 PM the Director of Nursing (DON) verified there was no documentation that Resident #416 received Toileting hygiene as needed. b) Resident #87 At approximately, 12:45 PM on 4/13/25, an interview was conducted with Resident #87. During the interview, the resident was asked if he received assistance from the staff 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 record review, observation, staff interview and resident interview, the facility failed to follow a physician's order for no straws for Resident #10 and failed to ensure Resident #26 received medication as ordered. These failed practices had the potential to affect more than a limited number of residents. Resident Identifiers: #10 and #26. Facility Census: 111. Findings included: a) During the initial interview process on 04/14/25 at 11:00 AM, the state surveyor observed a straw in Resident #10's water pitcher. Additional observations with the straw in the resident's water pitcher were completed at 12:16 PM, and 12:40 PM. The resident reported she drinks water out of the pitcher. Review of the resident's eating task found the resident to be set-up to independent for eating. At 12:50 PM, Registered Nurse #69 reported the resident had no straws because they were a high risk for aspiration. The straw was not removed at that time. The straw was observed to be removed from the water pitcher at 1:18 PM. Registered Nurse #69 stated, I know her well. At 01:45 PM, the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician of a newly admitted resident's indwelling catheter, and failed to obtain a physician's order for the care and maintenance of the catheter. In addition, the facility failed to provide the appropriate catheter care to prevent potential Catheter Associated Urinary Tract Infections (CAUTI's). This was true for one (1) of five (5) residents reviewed for catheter care. Resident Identifier: #266. Facility census: 111. Findings Included: a) Resident #266 During an interview on 04/13/25 at approximately 2:14 PM, Resident #266 stated she was looking forward to getting her catheter removed. Upon being asked if the facility provided catheter care, resident stated the staff usually emptied her catheter bag when it filled up. A review of the Minimum Data Set (MDS) data presented to the surveyors upon entry indicated Resident #266 was admitted to the facility on [DATE]. The MDS did not show Resident #266 had an indwelling urinary…

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

Based upon record review and staff interview, the facility failed to ensure resident received mental health referral and treatment. This was true for 1 (one) of 38 (thirty-eight) residents reviewed during this annual survey process. Resident identifier: #110. Facility census: 111 Findings included: A) Resident #110 A review of Resident #110's medical record found the following: Diagnosis Included: Post traumatic stress disorder Anxiety Disorder Depression A review of the MDS quarterly assessment on 04/03/25, recorded the following: Section D - Mood D0160: Total severity score of 18 D0170 Social Isolation was marked as always feeling lonely or isolated from those around you. Section E - Behavior Verbal behaviors towards others occuring 4 - 5 days per week Section I - Active Diagnoses Psychiatric/Mood Disorder: Anxiety Disorder Depression Post Traumatic Stress Disorder The most recent PASARR: Was completed on 02/04/25 by (Name of Local Hospital) and contained the following: Q23 Medical conditions/symptoms: Mental disorders None Section III: MI/MR Assessment Current diagnosis: None is…

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

Based on record review and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled to enable them to identify and correct any possible drug diversions. There were some discrepancies related to Resident #97's controlled substance log. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #97. Facility Census: 111. Findings Include: a) Resident #97 A review of Resident #87's medical record on the morning of 04/16/25 found the resident was ordered Hydrocodone 5-325 by mouth every 6 hours for pain, The medication administration record for the month of 03/2025 and the month of 04/2025 along with the controlled substance log coinciding with these months was requested. Upon review of the MAR and the controlled substance log it was found on 03/21/25, a nurse signed out…

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

Based on record review, and interview, the facility failed to ensure the attending physician reviewed and acted on the Consulting Pharmacist's recommendations. In addition, the facility failed to ensure that the physician reviewed and documented a response to the recommendations. This was true for five (5) of five (5) residents surveyed. Resident Identifier: Resident #17, # 28, #53, #74 and #87. Facility Census: 111. Findings include: a) Resident #17 On 04/14/25 at 3:11 PM a review of the Consulting Pharmacist's review for Resident #17's medications revealed the following: The Consulting Pharmacist's medication review on 09/20/24 showed the following recommendations: Resident is on Quetiapine 25 MG at bedtime for muscle weakness. This is not an appropriate diagnosis. Recommendation: An antipsychotic medication should be used only for the following conditions/diagnoses. Please check the appropriate indication for this resident: Huntington Disease Mood disorders (e.g. bipolar disorder, severe depression refractory to other therapies and/or with psychotic features) Medical illnesses…

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 Resident #70's medication regimen was free from unnecessary antipsychotic medications. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long-term care survey process. Resident identifiers: #70. Facility's Census: 111. Findings Include: a) Resident #70 On 04/14/25 at 9:05 PM the facility was entered on the night shift due to resident complaints of care on the night shift. Upon entrance to the facility Resident #70 was observed sitting in the doorway of the Cafe, the resident was yelling for help and asking for a snack. She later began asking for a specific snack of a peanut butter sandwich. Numerous staff were in the area and could have easily heard her asking for a snack. This continued until about 9:33 PM when Nurse Aide (NA) #55 walked by and she asked her for a peanut butter sandwich. NA #55 then stated to another employee, I think she is puree I will get her an apple sauce or pudding in just one (1) minute. Shortly after this…

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 failed to update orders to discontinue dialysis access care, and monitoring of the dialysis access graft/fistula. In addition, the facility failed to update orders and a care plan when a C-collar was discontinued. Resident Identifiers: #88, and #10. Facility Census: 111. Findings Include; a) Resident #88 During an interview, on 04/15/25 at approximately 1:20 PM, Resident #88 stated the dialysis access in her right upper arm was no longer patent. The resident stated he now had a dialysis catheter in her right upper chest, which was used during hemodialysis treatments. Record review on 04/15/25 at approximately 2:15 PM revealed the following order dated 10/08/24: External hemodialysis catheter 2 lumens (location) right chest wall with transparent dressing. DO NOT Change END caps. Further record review revealed the following orders dated 08/31/24: AV fistula/graft location: right upper extremity Change AV fistula/graft site dressing every Thursday Monitor AV fistula/graft site for S/S infection, edema, bleeding and upon…

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 bed rails were implemented within accepted standards of care. Three (3) of three (3) residents reviewed for the care area of bed rails did not have current orders for bed rails. One (1) of three (3) residents reviewed for the care area of bed rails did not have valid informed consent for bed rails. Resident identifiers: #12, #15, #96. Facility census: 111. Findings include: a) Policy and Procedures The facility's policy titled Bed Rails with effective date 07/01/18 and revision date 09/01/22 stated if the Bed Rail Evaluation determines that the patient would benefit from side rails, an order for the bed rails would be obtained from the physician or advanced practice provider (APP). The policy also stated informed consent would be obtained from the resident or, if applicable, the resident representative. b) Resident #12 Based on observation, record review, and staff interview, the facility failed to ensure bed rails were implemented within accepted standards of care. Three (3) of three (3)…

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 foot care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of foot care. Resident identifier: #12. Facility census: 111. Findings include: a) Resident #12 On 07/18/24, The Office of Health Facility Licensure and Certification received that Resident #12's toenails had not been cut since he was admitted to the facility. Review of Resident #12's medical records showed the resident was admitted in February 2024. The resident had a diagnosis of type 2 diabetes mellitus. No nail care was documented in the medical records. On 08/28/24 at 9:08 AM, Resident #12's toenails were observed with assistance from Registered Nurse (RN) #59. They were somewhat long. The left great toe was discolored and was cream and light gray colored. RN #59 stated the podiatry service comes to the building every three (3) months. RN #59 stated Resident #12 would be seen by podiatry on their next visit. Review of the facility's…

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

Based on record review, staff interview and observation, the facility failed to provide adequate supervision to residents and to maintain an environment free of accident hazards. This failed practice was found true for (1) one of (1) one resident reviewed for accident hazards during the survey process. Resident identifier: #111. Facility Census 111. Finding Include: a) Resident #111 A review of the facilities reportables, on 08/29/24 at 8:45 AM, revealed a reportable dated 06/28/24 alleging Resident #11 was witnessed drinking from a bottle of wound cleanser which was left on the crash cart. A record review on 08/29/24 at 8:50 AM, revealed a general progress note date 06/28/24 which read as follows: Resident was witnessed drinking from a bottle of wound cleanser; another resident reported to nursing resident had consumed content from a bottle, staff immediately responded; Resident denied pain or distress; no obvious signs of GI discomfort noted upon assessment; resident denied burning or discomfort to mouth; mouth care provided; resident continued to repeat I am o.k.; Resident has…

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 residents received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed. This deficient practice had the potential to affect (1) of four (4) residents reviewed during the investigation. Resident identifier: #39. Facility census: 110. Findings included: a) Resident #39 Resident #39 had the following physician-ordered medication parameters: - Amlodipine besylate, 10 mg, one (1) tablet by mouth one (1) time a day for hypertension. Hold for pulse below 60 or SBP [systolic blood pressure] less than 110 or DBP [diastolic blood pressure] less than 70 and notify provider, ordered on 02/23/23. - Propranolol, 20 mg, one (1) tablet by mouth two (2) times a day for hypertension. Hold for pulse below 60 or SBP less than 110 or DBP less than 70 and notify provider, ordered on 01/08/24. According to the resident's Medication Administration Record (MAR), at the following dates and times, amlodipine besylate was administered despite the resident's…

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

Based on observation, record review and staff interview, the facility failed to ensure services to meet professional standards of care. A medication labeled by the pharmacy to be used for a specific resident was used for another resident. This was a random opportunity for discovery found during medication administration observation. Resident identifiers: #4 and #52. Facility census: 110. Findings included: a) Residents #4 and #52 The facility's policy titled Medication Administration General Guidelines dated January 2024 gave the following procedure: - Medications supplied for one resident are never administered to another resident. On 07/18/24 at 7:38 AM, Licensed Practical Nurse (LPN) #28 was observed administering medications to Resident #4. The resident had an order written on 06/25/24 for Lactulose, 10 grams in 15 milliliters concentration, give 45 ml by mouth two (2) times a day for hyperammonemia (high ammonia level). LPN #28 could not find lactulose for Resident #4. There was an unopened Lactulose bottle with a label for Resident #52. The Lactulose concentration was 10 grams…

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 failed to provide a qualified activity professional for recreational services. This failed practice was a random opportunity for discovery and had the potential to affect all residents. Facility census: 110. Findings included: a) Activity Professional On 12/12/2023 at 3:00 PM the appointed Recreation Director (RD) #105 stated she has not had the activity professional qualification course but was set to have it in the upcoming January 2024 class. During an Interview on 12/13/2023 at 10:00 AM the Administrator stated the RD was enrolled into the Modular Education Program for Activity Professionals (MEPAP) course in November 2023 through National Certification Council for Activity Professional (NCCAP). Record review showed a copy of the enrolment email for RD #105 to attend the (MEPAP) course with an enrollment date of 11/03/23. During an interview on 12/13/23 at 11:03 AM Activity Consultant Certified (ACC) #301 Instructor verified the facilities recreation director was enrolled in MEPAP the course starting January 8th, 2024. ACC…

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 facility policy review, record review and staff interviews, the facility failed to ensure resident to resident altercations were reported to all the proper State Agencies. This is true for four (4) of ten (10) incidents reviewed for resident to resident alterations. Resident Identifiers: Resident #83, Resident #92, Resident #79, Resident #40, Resident #95, Resident #11 and Resident #54. Facility Census: 110. Findings Included: A review of a facility policy titled OPS300 Abuse Prohibition: with a revision date of 10/24/22 read as follows. .Process: .7.4 Report allegations to the appropriate state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source) suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. .9. The Administrator or designee will: .9.2 Report findings of all the completed investigations within five (5) working days to the Department of Health using the state on-line reporting system or state approved forms. A review of the…

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

Based on record review and staff interviews, the facility failed to ensure one (1) of four (4) residents reviewed, who were unable to carry out activities of daily living, received services to maintain personal hygiene. Resident Identifiers: Resident #105. Facility census: 110. Findings included: a) Resident #105 During a record review on 09/26/23 at 7:30 PM, Resident #105 medical record reviews revealed a showers schedule indicated Resident #105 should receive showers on Mondays, Wednesdays and Saturdays. Further record review revealed Resident #105 received showers on the following days: -09/02/23 -09/06/23 -09/10/23 -09/13/23 -09/16/23 -09/18/23 Bed Bath -09/22/23 Bed Bath This documentation indicated Resident #105 did not receive a shower on the following scheduled days and was coded Not Applicable: -09/04/23 -09/09/23 -09/11/23 -09/18/23 -09/20/23 -09/23/23 -09/25/23 During the record review on 09/26/23 8:02 PM, Medical record review revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/23 revealed the following: Section G, titled Activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician-ordered medication parameters were not followed for one (1) of three (3) residents reviewed receiving antihypertensive medications. Resident identifier: #105. Facility census: 110. Findings included: a) Resident #105 Review of Resident #105's physician's orders showed an order written on 09/08/23 for carvedilol 3.125 mg, one (1) tablet by mouth, two (2) times a day, for hypertension, at 8:00 AM and 8:00 PM. The medication was to be held if the resident's blood pressure was less than 110/60 or heart rate below 60. Review of Resident #105 Medication Administration Record (MAR) for September 2023 showed the resident's blood pressure was not recorded on the [DATE]/08/23, 09/09/23, and 09/10/23. According to the MAR, the resident's carvedilol had been administered at 8:00 AM on 09/08/23, at 8:00 AM and 8:00 PM on 09/09/23, and at 8:00 AM and…

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

Based on observation, record review and staff interview, the facility failed to provide nutritional adequacy by providing inconsistent portions of the food to maintain perimeters of health. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen. Facility census: 110. Findings included: a) Inconsistent Portions During a tour of the kitchen on 09/26/23 at 12:30 PM with the Director of Dining Services (DDS)#23 revealed the following issues: -During the observation [NAME] #27 was preparing the lunch meal trays from the serving steam table of meatball subs. The meatball subs were getting two (2) meatballs, some three (3), then she was cutting some in half and placing them on the buns. The DDS #23 stated the meatballs are not the 4 ounce size called for on the menu, I think those are bigger, was unable to tell this surveyor how many ounces was being provided to each resident. The menu stated two (2) four (4) ounce meatballs. -Cook #23 was serving french fries with a gloved hand and placing them on the Resident's plate,…

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, observation, staff, and resident interview, the facility failed to ensure Resident #6 was provided with the appropriate supplemental oxygen. This failed practice was true for one (1) of three (3) residents reviewed for oxygen therapy. Resident identifier: #6. Facility census: 118. Findings included: Record review showed an order with start date of 10/31/22 for Oxygen at 2 liters/minute via Nasal Cannula continuous, every day and night shift. On 09/14/23 at observation was made of Resident #6 eating lunch in the dining hall sitting in her wheelchair. Resident #6 was noted not have any supplemental oxygen in use. Resident #6's wheelchair did not have any portable O2 attached for use and no portable tank was located within the dining area belonging to the Resident. Licensed Practical Nurse (LPN) #45 was present in the dining room and verified Resident #6 was not wearing O2. LPN #45 stated, I have never seen [resident's first name] wear O2 while up in her wheelchair, but if the order says continuous then it should be on. Record review showed Resident #6 to have…

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.