Retreat, The

In the surveyor’s words

From the most serious findings on record at Retreat, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 26, 2023

  Based on interviews, record review, and facility policy review, it was determined the facility failed to provide cardiopulmonary resuscitation (CPR) for a resident who had an order for full code (all resuscitation procedures will be provided to keep a person alive if their heart stops beating or they stop breathing) for 1 (Resident #1) of 5 residents reviewed for CPR. Specifically, Resident #1 had an order for full code and was found unresponsive, without a pulse or respirations, on [DATE] and staff did not provide CPR. This had the potential to affect 12 of 44 residents who resided in the facility and had elected full code. […]

• Immediate jeopardy, isolatedF656May 13, 2021

  Based on record review and staff interview, the facility failed to provide Cardio-Pulmonary Resuscitation (CPR) as care planned for one resident (R) (R#1) of 11 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing Services (DON), and the facility's Health Services Administrator were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:46 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. […]

• Immediate jeopardy, isolatedF678May 13, 2021

  Based on record reviews, review of the facility's policy Code Blue, and staff interviews, the facility failed to provide Cardio-Pulmonary Resuscitation (CPR) for one resident (R) (R#1) of 11 residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing Services (DON), and the facility's Health Services Administrator were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:46 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Mar 3, 2025

  Based on observations, staff interviews, and a review of the facility's policy titled Food Storage, the facility failed to ensure that expired food items were discarded in the refrigerator and dry food storage pantry. The deficient practices had the potential to place 46 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include: A review of the facility's undated policy titled Food Storage revealed the Procedure section included, . 7. b. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS (temperature controlled food) food should be consumed, sold, or discarded. 12. […]

• No harm, potential for more than minimal, isolatedF880Apr 30, 2026

  Based on observations, staff and resident interviews, record review, and review of the facility policies titled Infection Prevention and Control Program Plan, the facility failed to use appropriate infection control practices when providing respiratory therapy for one resident (R) (R41) out of seven residents sampled. Specifically, A nebulizer facemask was laying on the dresser on top of a ziplock bag uncovered. This deficient practice had the potential to cause an infection.Findings include:Review of the policy titled Infection Prevention and Control Program Plan , revised 09/01/2025, revealed The Infection Prevention and Control Program of [NAME] Health Services, INC shall ensure that this organization develops, implements and maintains an active, organization wide program for the… […]