The Grove Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility's P&P review, the facility failed to provide the adequate and appropriate pain management for one of one final sampled resident reviewed for pain management (Resident 49). * The facility failed to ensure an accurate pain level was assessed and documented prior to the administration of the pain medication for Resident 49. * The facility failed to ensure non-pharmacological interventions were provided prior to the administration of the pain medication for Resident 49. These failures had the potential for Resident 49 to not receive the appropriate pain management. Findings: Review of the facility's P&P titled Pain Management dated 3/17/25, showed the facility will use pain assessment tool, which is appropriate for Resident's cognitive status, to assist staff in consistent assessment of a resident's pain. Under the section pain management and treatment showed non-pharmacological intervention will include but are not limited to: - Environmental comfort measures…

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 5. Medical record review for Resident 50 was initiated on 6/16/25. Resident 50 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 50's Order Summary Report showed a physician's order dated 1/3/24, for insulin glargine 23 units to be administered by subcutaneous injection at bedtime for diabetes. Review of Resident 50's Location of Administration Report for the months of May and June 2025, showed Resident 50's insulin injections sites were not rotated on the following dates and times: - On 5/7/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/8/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/9/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/13/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower…

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.

3. Review of the facility's P&P titled Medication Storage dated 1/2025 showed outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, dispose disposed off according to procedure for medication disposal, and reorder from the pharmacy if a current order exists. On 6/17/25 at 0846 hours, an inspection of Treatment Cart A was conducted with LVN 5. Multiple packets of Dermaseptin ointments and Dermarite Boarder Gauzes, each packaged in separate plastic, were observed without the expiration date. LVN 5 verified the observation and stated multiple staff including other treatment nurses, LVNs, used Treatment Cart A. LVN 5 stated the staff should have labeled the multiple Dermaseptin ointments and Dermarite Boarder Gauzes with an expiration date when they were removed from the original box stored in the medication room. On 6/18/25 at 1304 hours, the DON was informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, 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 2. Medical record review for Resident 27 was initiated on 6/16/25. Resident 27 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 27's Nutrition Progress Note dated 6/2/25 at 1716 hours, showed Resident 27 preferred Korean food for lunch and dinner. On 6/17/25 at 1320 hours, an observation was conducted of Resident 27. Resident 27 was observed lying in bed asleep. Resident 27's lunch tray was observed on a bedside table adjacent to Resident 27's bed. Resident 27's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). 3. Medical record review for Resident 96 was initiated on 6/16/25. Resident 96 was admitted to the facility on [DATE]. Review of Resident 96's Nutrition Progress Note dated 6/2/25 at 1454 hours, showed Resident 96 preferred Korean food at lunch and dinner. On 6/17/25 at 1246 hours, an observation was conducted of Resident 96. Resident 96 was observed…

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, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 61) observed during the dining observation task received the appropriate mechanically altered diet as ordered by the physician. This failure posed the risk of aspiration and resident's nutritional needs not being met. Findings: Review of the facility's P&P titled Therapeutic Diet Orders revised 11/2024 showed the therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets are provided only when ordered by the attending physician or a registered or licensed dietitian who has been delegated to write diet orders, to the extent allowed by state law. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of the International Dysphagia Diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment…

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 3. On 6/19/25 at 1129 hours, an observation of the facility's laundry room and concurrent interview was conducted with the Laundry Aide. The counter designated for clean laundry sorting was observed with clean bed linens folded and stacked on top of the counter. The Laundry Aide's cell phone charger, plastic water bottle, and water [NAME] were observed stored on the clean laundry counter adjacent to the clean resident bed linens. The Laundry Aide verified the findings and stated his personal items should not be stored adjacent to resident clean linens. On 6/19/25 at 1133 hours, an interview was conducted with the IP. The IP stated the staff's personal items should not be stored on the residents clean laundry sorting area adjacent to the clean resident laundry, to prevent contamination of the clean residents' laundry from potentially unclean staff personal items. 2. On 6/16/25 at 1031 hours, initial tour of the facility, an observation and concurrent interview for Resident 85 was conducted with CNA 4. Resident 85…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to offer PCV15 or PCV 20 vaccination to one of five final sampled residents (Resident 23) reviewed for immunizations. * Resident 23 received the PPSV23 vaccine on 12/5/13, however, the facility failed to offer Resident 23 PCV15 or PCV 20 vaccination, in accordance with the facility's P&P and CDC's recommendations. This failure increased the resident's risk for being inadequately vaccinated for the pneumococcal disease and its associated complications. Findings: Review of the CDC's guidelines for pneumococcal vaccination showed adults aged 65 years and older, who had only received PPSV23 vaccination (regardless of risk conditions) are to receive one dose of PCV15 or PCV20 at least one year after the most recent PPSV23 vaccination. Review of the facility's P&P titled Pneumococcal Vaccine Series dated 12/19/22, showed it is the facility's policy to offer residents immunization against pneumococcal disease in accordance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, the facility failed to ensure the necessary care and services were provided to meet the needs for one of two final sampled residents (Resident 1). * The facility failed to ensure Resident 1's levothyroxine medication was continued upon his discharge from the acute care hospital. This failure had the potential to affect Resident 1's health and wellbeing. Findings: Closed medical record review for Resident 1 was initiated on 11/19/24. Resident 1 was admitted to the facility on [DATE], from the acute care hospital and discharged on 11/9/24. Review of Resident 1's acute care hospital H&P examination dated 10/22/24, showed Resident 1 [NAME] history of hypothyroidism. Review of Resident 1's ED Patient Education and Visit Summary from the acute care hospital dated 10/22/24, the section for Final Active Medication List showed an order for levothyroxine (a medicine used to treat an underactive thyroid gland) 100 mcg orally one tablet daily before breakfast on an empty…

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, interviews, and facility policy reviews, the facility failed to ensure an assessment was completed before they applied a bolster mattress to 1 (Resident #292) of 1 sampled resident reviewed for physical restraints to determine whether the bolster mattress was a physical restraint. Findings included: A review of the facility policy titled, Restraint Free Environment, implemented on 12/19/2022, revealed Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definitions: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. According to the policy, 5. Before a resident 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 interviews, record review, and facility policy review, the facility failed to ensure a level II mental health evaluation was completed for 1 (Resident #4) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A review of a facility policy titled, Resident Assessment - Coordination with PASARR Program revised on 12/18/2023, revealed, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. Per the policy, b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility P&P review, the facility failed to ensure the safe food handling practices and sanitary conditions were maintained in the dietary services as evidenced by: * The facility failed to ensure the food items were labeled with an open date and/or received date, the expired food items and dented cans were discarded, and the food items were not exposed to leaking water from the refrigerator condenser (one of the main operating components that make up the cooling system on a standard refrigerator). The facility also failed to ensure the facility staff's personal food items were not stored in the walk-in refrigerator and dry storage room; and the facility staff's personal belongings were not stored in the food preparation area or on top of the clean towels used for cleaning the surfaces in the kitchen. * The facility failed to ensure the dishwashing chlorine sanitizer met the required concentration as per the facility's P&P. These failures had the potential to cause food borne…

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, medical record review, and facility P&P review, the facility failed to implement their infection control P&Ps designed to provide a safe and sanitary environment; and help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to implement their P&P related to caring for the residents who were known or suspected to have COVID-19 by donning full PPE as per the facility's P&P. * The facility failed to identify, test, and prevent Legionella (a bacteria that can cause a serious type of lung infection) and other opportunistic waterborne pathogens These failures had the potential for cross-contamination and spread of infectious organisms in the facility. Findings: 1. Review of the facility's P&P titled Infection Control Manual-Coronavirus (COVID-19) dated 3/30/22, showed full PPE should be worn as per the CDC guidelines for the care of any resident with known or suspected COVID-19. PPE includes gloves, isolation gowns, facemasks, face…

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

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 442) self- administered the medication only as ordered by the physician. * During the medication pass observation, LVN 3 provided ofloxacin solution (antibiotic medication) 0.3 % bottle to Resident 442. Resident 442 self- administered the ofloxacin ear drop medication; however, there was no physician's order for Resident 442 to self-administer the ear drop medication. This failure had the potential risk for Resident 442 for unsafe self-administration of the medication. Findings: Review of the facility's P&P titled Preparation and General Guidelines IIA2: Medication Administration-General Guidelines dated October 2017 showed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Medical record review for Resident 442 was initiated on 11/28/22. Resident 442 was admitted in the facility on 11/7/22. 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 interview, medical record review, and facility P&P review, the facility failed to determine whether one of 18 sampled residents (Resident 61) had formulated an advance directives. This had the potential for the resident's decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Physician Orders for Life Sustaining Treatment (POLST) revised 9/30/20, showed the facility will provide the Resident/Segregate decision-maker the option to complete or honor a POLST or complete the Preferred Intensity of Care form at the time of admission. On 11/28/22 at 1500 hours, review of Resident 61's medical record was initiated. Review of Resident 61's POSLT form showed the section to document whether Resident 61 had an advance directive was left blank. On 12/1/22 at 0808 hours, an interview and concurrent medical record was conducted with the Social Services Assistant. The Social Services Assistant verified the section to document whether Resident 61 had an advance directive was not completed but should have been completed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to notify the physician when one of 18 sampled residents (Resident 1) refused the medication as per their P&P. This failure had the potential risk to affect the resident's health. Findings: Review of the facility's P&P titled Refusal of Medications and Treatments dated April 2001 showed documentation pertaining to a resident's refusal or treatment shall include the date and time the physician was notified as well as the physician's response. The physician and DON should be notified if the resident refuses two doses of medication or two treatments. Medical record review for Resident 1 was initiated on 11/29/22. Resident 1 was readmitted to the facility on [DATE]. Review of the MDS quarterly assessment dated [DATE], showed Resident 1 was cognitively intact. Review of Resident 1's history and physical examination dated on 5/11/22, showed diagnoses of quadriplegia (a paralysis that affects all a person's limbs and body from 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, interview, and medical record review, the facility failed to implement the plan of care of one of 18 final sampled residents (Resident 58) related to fall prevention. This posed the risk for the resident to sustain the repeated falls. Findings: Medical record review for Resident 58 was initiated on 11/29/22. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's History and Physical Examination dated 11/26/22, showed the resident had the capacity to understand and make decisions. Review of the MDS Section G Functional Status dated 8/18/22, showed Resident 58 required extensive physical assistance of one person for transfers, bed mobility, and locomotion. The MDS Section J Health Conditions dated 8/18/22, showed Resident 58 had one fall incident in the facility with injury. Review of Resident 58's Nurses Progress note dated 8/11/22, showed Resident 58 was resting in her bed after finishing her dinner meal when Resident 58 tried to transfer herself unassisted to her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the non-pharmacologic interventions were attempted for one of 18 final sampled residents (Resident 16) prior to initiating the use of psychotropic medication (drug that affects brain activities associated with mental processes and behaviors). In addition, the facility failed to monitor Resident 16's targeted behavior for the use of the psychotropic medication. This failure had the potential for unnecessary medications, which placed the resident at risk for experiencing harmful adverse effects from the psychotropic medications. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 6/2021 showed the facility should involve the resident or the resident's representative(s) in the discussion of potential non-drug and medication interventions to address and management of behaviors. The involvement should be documented in the resident's medical record. Facility staff should document the number…

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

Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 14.81% during the medication administration observations as evidenced by: * Resident 442 had physician's orders to administer fluticasone-salmeterol aerosol powder breath activated (medication that helps control the symptoms of asthma and improve breathing) 500-50 mcg one puff inhale orally two times a day; and ofloxacin solution 0.3 % (used to treat infection of the ear canal) instill three drops in the left ear two times a day for left otitis media ok to use in ear. However, LVN 3 failed to administer the medications as per the facility's P&P. * Resident 191 had physician's order to administer bisacodyl suppository (medication to relieve constipation) 10 mg insert rectally for bowel management, hold if having loose stool. However, LVN 1 administered the medication even when Resident 191 had episodes of loose stools. *Resident 30 had the physician's order to administer metformin hcl metformin (oral…

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

Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals as per the facility's P&P in one medication room (Station 1 Medication Room). * The facility failed to ensure Resident 191's medication was disposed after the medication's expiration date. This failure had the potential for the medication to be accidentally administered and/or diverted. Findings: Review of the facility's P&P titled Disposal of Medications and Medication-Related Supplies IE3: Discontinued Medications dated December 2018, showed when the medications have expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked discontinued or stored in a separate location and later destroyed. On 11/29/22 at 0803 hours, an inspection of the Station 1 Medication Room was conducted with RN 1. One bottle of lansoprazole (proton pump inhibitor) solution was observed with an expiration date of 11/7/22. RN 1 verified the above finding and stated 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 interview and medical record review, the facility failed to ensure the arbitration agreement was explained to one nonsampled resident (Resident 76). This failure posed the risk for the resident to not have the right to file an appeal if there was any issue of medical malpractice. Findings: Review of the facility's P&P titled Binding Arbitration Agreements dated 2022 showed when explaining the arbitration agreement, the facility shall: - Explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission or as a requirement to continue to receive care at this facility. - Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. - Ensure the resident or his or her representative acknowledges that he or she understands the agreement. Review of Resident 76's medical record was initiated on 11/28/22. Resident 76 was…

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

Based on interview, facility document review, and facility P&P review, the facility failed to implement their P&P addressing antibiotic stewardship program designed to monitor infections and implement actions to ensure the appropriate use of antibiotics for one final sampled resident (Resident 30) and five non-sampled residents (Residents 24, 27, 28, 59, and 291) as evidenced by: * The facility failed to ensure the McGeer's criteria was utilized when considering initiation of antibiotic medication and at 72 hours after administration of antibiotic medication, each resident was reassessed for consideration of antibiotic need. The Infection Control Surveillance Log for November 2022 failed show documentation that the residents who were prescribed antibiotic medication had signs and symptoms of the conditions indicated. Without documentations on the signs and symptoms of the infection, the facility was unable to determine whether the infection met the McGeer's criteria for a true infection. In addition, the November 2022 Healthcare Associated Infections Summary Report of new cases 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.