Park Regency Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nutritional interventions were followed for one nonsampled resident (Resident 81) reviewed for nutrition. * The facility failed to ensure the physician's order for fluid restriction was followed and documented properly for Resident 81. This failure had the potential to negatively affect the resident's health and well-being. Findings: On 12/9/25 at 0910 hours, during the initial tour of the facility, Resident 81 was observed in bed awake. A posted signage for fluid restriction on the wall of Resident 81's head of bed was observed. A water pitcher and a half full bottle of colored drink were observed on top of the over the bed table. Medical record review for Resident 81 was initiated on 12/10/25. Resident 81 was admitted to the facility on [DATE]. a. Review of Resident 81's Order Summary Report for December 2025 showed a physician's order dated 11/26/25, for fluid…

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 two final sampled residents (Residents 38 and 78) investigated for respiratory status were provided with the appropriate respiratory care and services. * The facility failed to ensure Resident 38 had a physician's order for the resident's oxygen use. * Resident 78's nasal cannula was observed on the floor, and undated. In addition, the resident's nebulizer mask and tubing were observed on top of the drawer, uncovered. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.Findings: Review of the facility's P&P titled Oxygen Administration revised 5/20/24, showed to verify there is a physician's order for this procedure and review the physician's order or facility protocol for oxygen administration. The facility staff shall change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. 1. On 12/9/25 at 0900…

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, medication label review, facility P&P review, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.69%. Two of three licensed nurses (LVNs 1 and 3) who were observed during medication administration were found to have errors. * LVN 1 failed to ensure Macrobid (urinary antibiotic) medication was administered to Resident 77 with food and not crushed. * LVN 3 failed to ensure ursodiol (gastrointestinal agent) medication was administered to Resident 47 with food. These failures created the risk for the residents to have potential side effects or complications related to the medications. Findings: 1. Review of the FDA label dated 2021 for Macrobid showed the following:- Each Macrobid capsule contains two forms of nitrofurantoin, 25% is macrocrystalline nitrofurantoin, which has slower dissolution and absorption than nitrofurantoin monohydrate. The remaining 75% is nitrofurantoin monohydrate…

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 one nonsampled resident (Resident 77) was free from significant medication error. * The facility failed to ensure the Macrobid (urinary antibiotic) medication was administered to Resident 77 with food and the medication was not crushed. This failure placed Resident 77 at risk for significant side effects and medical complications. Findings: Review of the FDA label dated 2021 for the Macrobid medication showed the following:- Each Macrobid capsule contains two forms of nitrofurantoin, 25% is macrocrystalline nitrofurantoin, which has slower dissolution and absorption than nitrofurantoin monohydrate. The remaining 75% is nitrofurantoin monohydrate contained in a powder bled which, upon exposure to gastric and intestinal fluid, forms a gel matrix that releases nitrofurantoin over time;- To take Macrobid with food (ideally breakfast and dinner) to further enhance tolerance and improve drug absorption. 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 observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner. * The facility failed to dispose of the expired medications in Medication Room A. * The facility failed to dispose of the expired medications inside Treatment Cart A. * The facility failed to ensure Medication Cart B was not left unlocked and unattended. These failures had potential to result in unsafe medication administration, cross-contamination of the medications, and posed the risk for non-licensed staff to have access to the medications.Findings: Review of the facility's P&P titled Medication Storage dated 12/19/22, showed the medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. The pharmacy and all…

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 personal food policy for one of 19 final sampled residents (Resident 76) was followed. * Resident 76 had a personal ice chest observed soiled and with food items inside. This failure posed the resident at risk of storing the food items which may cause food borne illnesses.Findings: On 12/09/2025 at 1445 hours, an observation and concurrent interview was conducted with Resident 76. CNA 7 was also present in the room. A purple ice chest was observed inside Resident 76's room. The ice chest was observed with brownish and yellowish stains scattered inside the ice chest, and contained two bananas and two melted ice packs. The findings were verified with CNA 7. When asked about the cleaning of the ice chest, CNA 7 acknowledged the staff were responsible for cleaning it. CNA 7 stated the ice chest had only been inside Resident 76's room one day. However, Resident 76 stated the ice chest had been in her room for a while. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility document review, the facility failed to conduct a regular bed inspection as part of a regular maintenance program to identify areas of possible entrapment for one of five residents (Resident 12) reviewed for side rails. * Resident 12's medical record failed to show documented evidence the entrapment assessment was conducted prior to the use of side rails. This failure had the potential to negatively impact the resident resulting in possible entrapment, serious injuries, and death.Findings: On 12/9/25 at 0937 hours, during the initial tour of the facility, Resident 12 was observed lying in bed, with the bilateral 1/4 (quarter) side rails elevated. Resident 12 was observed holding on to the right 1/4 (quarter) side rail while being changed by CNA 1. Medical record review for Resident 12 was initiated on 12/9/25. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 required partial/moderate 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 interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for two of three sampled residents (Residents 1 and 2). * The facility failed to develop a care plan to address Resident 1's wandering behavior by attempting to enter to other female rooms. * The facility failed to develop a care plan to address Resident 2's elopement risk. These failures posed the risk of the residents not receiving the appropriate treatment and services.Findings: Review of the facility's P&P titled Comprehensive Care Plans reviewed/revised 12/2022 showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. According to the Fundamentals of Nursing 10th edition,…

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 the necessary care and services were provided to promote the healing of a pressure injury for one of three sampled residents (Resident 3). * The facility failed to provide a LAL mattress for Resident 3 who had a Stage 3 pressure injury (characterized by full-thickness skin loss, where the damage extends into the subcutaneous tissue (fat). While adipose tissue (fat) is visible, bone, tendon, or muscle are not exposed. The wound may have a crater-like appearance, and slough (dead tissue) or eschar (a scab) may be present, but they do not obscure the depth of the wound. Undermining and tunneling (where the wound extends under the skin's surface) can also occur). This failure had the potential to cause and delay the healing of resident's pressure injury. Findings: Review of the facility's P&P titled Pressure Injury Prevention and Management revised 9/12/23, showed in part, this facility is committed to 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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for three of three sampled residents (Residents 1, 2, and 3). * Residents 1 and 2's care plan failed to properly address the use of floor mats for safety. * Residents 2 and 3's post fall neurological assessments were incomplete. These failures had the potential for adverse events related to falls to happen. Findings: 1. Review of the facility's P&P titled Fall Prevention Program dated 12/28/23, showed the nurse and/or interdisciplinary team will initiate interventions on the resident's care plan. a. Medical record review for Resident 1 was initiated on 3/27/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. On 3/27/25 at 0817 hours, there were bilateral floor mats observed by Resident 1's bed. On 3/27/25 at 1215 hours, Resident 1 was observed in bed. The resident's bed was in the lowest position and the bilateral floor mats were…

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

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 two of three sampled residents (Residents 1 and 3) remained free from accident hazards. * The facility failed to assess Residents 1 and 3's ability to handle containers and consume the hot beverages as per the facility's P&P. In addition, Resident 1 spilled a cup of hot chocolate on her left shoulder extending down to the posterior back causing redness and blisters to Resident 1's left shoulder and left upper back. These failures posed the risk of injury to the other residents who were consuming hot liquids in the facility. Findings: Review of the facility's P&P titled Hot Liquid Safety revised 12/19/22, showed all the residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices to drink hot liquids. Interventions will be individualized and noted on the resident's plan of care. Interventions…

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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the heavy-duty blenders used for puree preparation were air dried prior to storing. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 10/8/24, showed 87 of 95 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Dish and Utensil Procedure revised date 3/3/20, showed chipped or cracked dishes, trays shall be discarded. According to the USDA Food Code 2022 Section 4-502.11…

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, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for 15 of 15 residents (14 final sampled residents, Residents 12, 13, 23, 33, 44, 47, 49, 77, 80, 83, 85, 87, 540, and 541 and one nonsampled resident, Resident 24) reviewed for side rail use. This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between 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, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for one of 19 final sampled residents (Resident 540) and four nonsampled residents (Residents 9, 17, 81, and 740). * The facility failed to ensure the call lights were within reach and accessible for Residents 9, 17, and 740. * The facility failed to ensure the bed control was within reach and accessible for Resident 81. * Resident 540's call light button was observed not working. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to receive care. Findings: Review of the facility's P&P titled Call Lights Accessibility and Timely Response revised on 12/19/22, showed the following: -The purpose of this policy is to assure the facility is adequately equipped with a call light; -Staff will ensure the call light is within reach of resident and secured, as needed; -The call system will be accessible…

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 information on how to formulate an advance directive was provided to one of 19 final sampled residents (Resident 33). In addtion, the facility failed to ensure the POLST form was complete and copy of advance direction was obtained and maintained the medical record for two of 19 final sampled residents( Resident 23 and 87). These failures had the potential for the facility to provide treatment and services against the resident's wishes. Findings: 1. Review of the facility's P&P titled Residents' Rights Regarding Treatment and Advance Directives revised date 12/19/22, showed it is the policy of the facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able…

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 maintain a clean and homelike environment for two of 19 final sampled residents (Residents 33 and 49) and two nonsampled residents (Residents 27 and 86). * Resident 86 was observed walking into resident Shower Room A to take a shower. Shower Room A was observed with a soiled towel on the bathroom floor and several unpackaged clean adult briefs lying on the floor and shower chair. * Resident 49 resided in Room C. Room C was observed with scratches and unpainted areas on the walls and bathroom door frame. The Room C curtains were observed with stains and discoloration. * Resident 27 resided in Room B. Room B was observed with scratches and unpainted areas on several areas of the walls. * Resident 33 resided in Room A. Room A was observed with scratches and chipped paint on several areas of the walls. These failures posed the risk for unsanitary conditions and had the potential to negatively impact the residents' quality of life. Findings: 1. On 10/9/24 at 0918 hours, an observation and concurrent interview was conducted 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, medical record review, and facility P&P review, the facility failed to ensure the Level 1 PASRR contained accurate information for two of 19 final sampled residents (Residents 53 and 77). * Resident 77 had a diagnosis of unspecified psychosis and major depressive disorder and was prescribed Seroquel (an antipsychotic); however the Level I PASRR showed Resident 77 had no diagnosed mental illness and was not prescribed psychotropic medications. * Resident 53 had a diagnosis of depressive disorder; however, the Level 1 PASRR screening showed Resident 53 had no diagnosed mental illness. These failures posed the risk for the residents' inappropriate placement in a long-term care nursing home when a PASRR Level II evaluation was not done. Findings: Review of the facility's P&P titled Resident Assessment-Coordination with PASRR Program revised 12/18/23, showed the facility coordinated assessments with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that…

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 of 19 final sampled residents (Resident 62) was free from the accident hazards. * The facility failed to place the floor mattresses on both sides of Resdient 62's bed as ordered by the physician and resident's care plan for Resident 62. This failure had the potential for serious injury to the resident. Findings: Review of the facility's P&P titled Fall Prevention Program revised date 12/28/23, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse and/or interdisciplinary team will initiate interventions on the resident's care plan, in accordance with the resident's level of risk. On 10/7/24 at 1026 hours, during an initial…

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 provide the necessary care and services to maintain the IV accesses for two of two residents (one final sampled resident, Resident 77 and one nonsampled resident, Resident 63) reviewed for IV care. * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the residents' medical records for Residents 63 and 77 upon admission to the facility. In addition, the facility failed to obtain a physician's order for the care and maintenance of the PICC line for Resident 77, failed to develop a plan of care for the use of PICC, and failed to ensure the PICC dressings were changed weekly as per the facility's P&P for Residents 63 and 77. These failures had the potential to delay the identification of catheter related complications for Residents 63 and 77. Findings: Review of the facility's P&P titled PICC/Midline/CVAD Dressing Change revised…

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 appropriate pain management for one of one final sampled resident (Resident 87) reviewed for pain management. * The facility failed to administer pain medication according to the physician's order for Resident 87. This failure had the potential for ineffective pain management for Resident 87. Findings: Review of the facility's P&P titled Pain Management revised 12/19/22, showed in order to help the resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Review of the facility's P&P titled Medication Administration revised 12/19/22, showed the medications are administered by licensed nurses, or other staff who are legally authorized to do…

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 provide the necessary care and services to attain and maintain the highest physical well-being for one of one final sampled resident (Resident 23) reviewed for dialysis. * The facility failed to ensure the intake and output for Resident 23 were monitored and documented as ordered. This failure had the potential for Resident 23 having an excess of fluids, which could affect other vital organs in the body due to the resident's impaired kidney function. Findings: Review of the facility's P&P titled Fluid Restriction revised 12/2022 showed it is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. Medical record review for Resident 23 was initiated on 10/7/24. Resident 23 was admitted to the facility on [DATE], with diagnoses including end stage renal disease requiring dialysis three days a week. Review of Resident 23's Order Summary Report dated 10/7/24, showed a…

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

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 four of 19 final sampled residents (Residents 53, 77, 80, and 83) and one nonsampled resident (Resident 24) remained free from the accident hazards due to the use of side rails. * The facility failed to ensure the Physician's Documentation of Informed Consent for Resident 83 was accurately completed, had missing physician's signature, and was undated. * The facility failed to ensure the physician's order was obtained and care plan was initiated for the use of side rails for Residents 77 and 80. * The facility failed to obtain the physician's order and initiate a care plan problem for the use of the bilateral half side rails for Residents 77 and 80. * The facility failed to ensure the Physician's Documentation of Informed Consent for Resident 83 was signed by the physician prior to Resident 83 using the bilateral side rails. * The facility failed to obtain informed consent prior to the use of elevated…

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, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation for the controlled medications for one of 19 final sampled residents (Resident 541) and three nonsampled residents (Residents 48, 741, and 742). * The facility failed to ensure the administration of the controlled medications for Residents 54, 741, and 742 were accurately reconciled and documented in the MAR. * The facility failed to ensure the administration of the controlled medication for Resident 48 was documented in the controlled drug record and MAR. * The facility failed to ensure the Controlled Substance Shift Count Log for Medication Cart C was completed every shift. These failures posed the risk for diversion of medications. Findings: Review of the facility's P&P titled, Medication Administration revised on [DATE], showed the following: - Keep medication cart clean, organized, and stocked with adequate…

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 five of five final sampled residents (Residents 13, 23, 77, 83, and 541) reviewed for unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 13's consent for Seroquel (antipsychotic medication) was signed and dated by the physician. * The facility failed to ensure Resident 83's consent for Risperdal (antipsychotic medication) was signed and dated by the physician. * The facility failed to ensure Resident 541 with prescribed Seroquel was monitored for orthostatic hypotension and number of behavior episodes; and provided non-pharmacological interventions. In addition, the facility failed to ensure the physician obtained a consent for the prescribed Seroquel medication and failed to ensure the behavior manifestation in the orders was accurate . * The facility failed to ensure Resident 77 was monitored for adverse side effects including orthostatic hypotension…

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 76) was free from the significant medication errors. * The facility failed to ensure Resident 76 received Keppra (anticonvulsant medication) and metformin (antidiabetic medication) due to leakage from medication cup. This failure had the potential to cause Resident 76 to have convulsion (a medical condition that causes the body to shake uncontrollably), high blood glucose and negatively affect the resident's health. Findings: Review of the facility's P&P titled Medication Administration via Enteral Tube revised 12/19/22, showed the following: - To ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practices guidelines; - Each medication will be administered separately, not combined, or added to an enteral feeding formula. On 10/8/24 at 0832 hours, medication administration observation and concurrent interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications for one nonsampled resident (Resident 740) in Medication Room A's refrigerator were discarded. * The facility failed to ensure the expired medications were removed from the current treatment supply in Treatment Cart A. * The facility failed to ensure the orally administered medications were stored separate from externally used medications and supplies in Medication Cart A. * The facility failed to ensure the medication bottles and medication tray were kept clean and free of sticky residue in Medication Cart A. * The facility failed to properly label the opened medications with the open date in Medication Cart A. * The facility failed to ensure the orally administered medications were stored separate from externally used…

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, facility document review, and facility P&P review, the facility failed to ensure the use and storage of food brought to the facility by the family members or visitors. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources. Findings: Review of the CMS S&C-09-39 dated 5/29/09, showed the residents have the rights to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. Review of the State regulations dated 2/3/23, showed the facility must have a policy regarding use and storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 1/25/24, showed it is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Medical record review for Resident 291 was initiated on 10/7/24. Resident 291 was admitted to the facility on [DATE]. Review of Resident 291's Physician Orders for Life-Sustaining Treatment (POLST) dated 9/25/24, showed Resident 291's advance directive was not available. However, review of Resident 291's Advance Directive Acknowledgment form dated 9/29/24, showed Resident 291 had not executed an advance directive. On 10/8/24 at 1439 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the discrepancy specific to if Resident 291 had formulated an advance directive. The SSD stated the information documented on Resident 291's POLST dated 9/25/24, specific to whether Resident 291 had formulated an advance directive was inaccurate. 3. Medical record review for Resident 49 was initiated on 10/7/24. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49's POLST dated 8/26/19, showed Resident 49's advance directive was not available. However, review…

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 two of five final sampled residents (Residents 23 and 80) reviewed for vaccinations were assessed for the COVID-19 vaccination status or offered the COVID-19 vaccine. This failure put the residents at risk for increased risk of infection and transmission of COVID-19. Findings: Review of the facility's P&P titled COVID-19 Vaccination revised 6/9/23, showed it is the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by educating and offering the residents and staff the COVID-19 vaccine. The COVID-19 vaccinations will be offered to the residents when the supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. 1. Medical record review for Resident 23 was initiated on 10/7/24. Resident 23 was admitted…

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 document review, the facility failed to ensure the essential equipment was maintained in safe operating condition. * The facility failed to ensure the glucometer quality control test was done and the results were accurately documented for two of two glucometer devices reviewed. This failure had the potential for the residents requiring glucose checks to have inaccurate readings. Findings: 1. On 10/9/24 at 1433 hours, a review of the Assure Platinum Glucose Monitoring System: Quality Control Record for October 2024 for Medication Cart A was conducted with LVN 7. The log showed the following: - on 10/8/24, the normal control result was 88 mg/dL and the high control result was 230 mg/dL. - on 10/9/24, the normal control result was 87 mg/dL and the high control result was 226 mg/dL. However, the above normal control and high control results were not observed on the glucometer device. LVN 7 verified the above findings. LVN 7 stated the 11-7 shift licensed nurses were responsible to perform and document the glucometer quality control test…

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 provide the necessary care and services for one of three sampled residents (Resident 2). * The facility failed to ensure the Bactroban (antibiotic ointment) ointment was applied during the wound care treatment as ordered by the physician for Resident 2. In addition, the facility failed to provide treatment in the sacrococyx (fusion between sacrum and coccyx) area as ordered by the physician for Resident 2. * The facility failed to ensure the Bactroban ointment was ordered and available for wound care as ordered for Resident 2. These failures had the potential for Resident 2 not to receive appropriate care and treatment. Findings: Review of the facility's P&P titled Wound Care revised July 2022 showed the purpose of the P&P is to provide guidelines for the care of wounds to promote healing. Under the section for procedure showed to verify the physician's order for the procedure. Medical record review for…

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 accuracy of the medical record for one of two sampled residents (Resident 1). This had the potential for the resident's care needs not being met as the clinical information was not accurate. Findings: Review of the facility's P&P on Fall Prevention Program showed eachresident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the facility's P&P titled Statement Charting and Documentation showed all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record, all observations, medications administered, services performed, etc., must be documented in the resident's clinical records, all incidents, accidents, or changes in the resident's condition must be recorded in the clinical record, 72 hour charting will be…

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

Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to implement their P&P to ensure proper storage of food items in the residents' refrigerator. The facility failed to ensure proper labeling and dating of food items in the refrigerator used for the residents' food brought in by the visitors. * The facility failed to ensure the kitchen equipment and utensils were clean. * The facility failed to air dry food storage containers used for food portioning. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population consuming food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 2/11/22, showed 79 of 88 residents in the facility received food prepared in the kitchen. According to the facility's P&P titled Food: Safe Handling for Foods from Visitors (undated), when the food items are intended for later consumption, the responsible staff member will…

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 document review, the facility failed to accurately assess a deteriorating pressure ulcer for one of 19 sampled residents (Resident 75). * Resident 75's pressure ulcer was evaluated as a Stage 2 pressure ulcer when the wound had deteriorated to an unstageable pressure ulcer. This failure posed the risk for the resident to not receive the proper care and develop complications from a pressure ulcer. Findings: According to the The National Pressure Injury Advisory Panel (NPIAP) document titled, NPIAP Pressure Injury stages defined Pressure Injury as a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. - Stage 1 pressure ulcer is intact skin with a localized area of non-blanchable erythema (skin redness that does not turn white when pressed). - Stage 2 pressure ulcer is a partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist and may also…

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 provide the necessary GT care and services for one of 19 final sampled residents (Resident 39) and one nonsampled resident (Resident 35). * The facility failed to ensure Resident 39 was administered the total amount of enteral feeding as ordered by the physician. Furthermore, the facility failed to notify Resident 39's primary physician of Resident 39's multiple refusals of GT feeding due to possible feeding intolerance. * The facility failed to ensure Resident 35 was positioned safely at 30-45 degrees during medication administration via GT. In addition, LVN 3 failed to perform hand hygiene before donning gloves and before administering the medications via GT. These failures posed the risk for developing complications related GT. Findings: 1. Review of the facility's P&P titled Enteral Nutrition revised November 2009 showed adequate nutritional support through enteral feeding will be provided to residents…

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 provide the necessary respiratory care and services for three of 19 final sampled residents (Residents 9, 17, and 379). * The facility failed to ensure a physician's order for oxygen was obtained for Resident 379 prior to oxygen administration. This failure had the potential for Resident 379 receiving unnecessary oxygen. * Resident 17's physician's order for the oxygen therapy settings did not match the oxygen settings included in the care plan. This failure posed the risk for the resident to not receive the appropriate amount of oxygen which may result in negative physical outcome. * Resident 9's nebulizer was placed on top of the trash can. This failure posed the risk for contamination of oxygen equipment and increasing the residents' risk for acquiring infection. Findings: 1. Review of the facility's P&P titled Oxygen Therapy revised 7/2018 showed oxygen will be administered as ordered by the physician or…

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 provide the necessary care and services to attain and maintain the highest practicable physical well-being for one of 19 final sampled residents (Resident 48). * The facility failed to consistently complete Resident 48's post dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) assessments when the resident returned to the facility from dialysis center. This failure had the potential to compromise the facility's ability to identify and address potential complications after dialysis. Findings: Review of the facility's P&P titled Renal Dialysis, Care of Residents reviewed 11/2017, under the section for Standard, showed access site care is checked for condition and patency every shift except on return from the dialysis unit. Under post dialysis care showed to take vital signs upon return from dialysis and every four hours for the first eight hours and to perform and document complete body check 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services and ensure accurate reconciliation of controlled medications for three of 19 final sampled residents (Residents 55, 69, and 75). * The facility failed to ensure administration of the controlled medications for Resident 55 was accurately documented to ensure accurate reconciliation and prevent the medication administration errors. In addition, several medications were not documented as administered to Resident 55 in the MAR on 1/28, 1/29, and 1/31/22. These failures created the risk for diversion of controlled medications and medication administration errors. * The facility failed to ensure administration of the controlled medications for Resident 69 was accurately documented to ensure accurate reconciliation and prevent the medication administration errors. This failure created the risk for loss or diversion of controlled medications. * The facility failed…

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 provide adequate monitoring of medications for one of 19 final sampled residents (Resident 64). *Resident 64 was receiving apixaban (blood thinner) and was not monitored for the adverse effect of bleeding. This failure had the potential to negatively impact the resident's well-being. Findings: According to the Highlights of Prescribing Information for apixaban, the medication increases the risk of bleeding and can cause serious, potentially fatal bleeding. Bleeding events in patients may include intracranial ( brain bleed), intraspinal (spinal bleed), intraocular ( bleeding in the eyes), pericardial (bleeding in the hear), intraarticular (bleeding in the joints), intramuscular (bleeding in the muscles), and gastrointestinal bleeding. Review of Resident 64's medical record was initiated on 2/9/22. Resident 64 was readmitted to the facility on [DATE]. Review of Resident 64's Order Summary Report showed a physician's order dated…

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

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 two of five unnecessary medication sampled residents' (Residents 55 and 64) psychotropic medications were monitored for its use. * The facility failed to ensure informed consents were obtained for Resident 55's use of Ambien (medication used to treat sleep problem) and duloxetine (antidepressant medication) medications. In addition, the facility failed to ensure Resident 55's behavior for the use of duloxetine medication was monitored as per the physician's order. * The facility failed to ensure Resident 64's behavior for the use of Prozac (medication for depression) was accurately monitored. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the facility's P&P titled General Guidelines for the Use of Psychoactive Medications revised 10/2017 showed informed consent for the psychoactive medication will be obtained from the resident or resident's representative.…

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 the medication error rate was below 5%. The facility's medication error rate was 18.52%. * LVN 3 failed to administer Resident 35's medications as ordered by the physician. Resident 35's eye drops was not administered as ordered because it was unavailable. Significant amounts of amlodipine (medication to control blood pressure, docusate sodium (stool softener), vitamin C (supplement and multivitamins with minerals (supplements) were left in the medication cups during medication administration via GT. In addition, LVN 3 failed to administer free water flushed in between the administration of four medications. These failures created the risk of complications and ineffective therapeutic effects of the medications. Findings: 1. Review of the facility's P&P titled Enteral Tube Medication Administration dated January 2017 showed if administering more than one medication, flush with 5 ml of water or prescribed amount, between each medication. On 2/8/22 at 0929 hours, a medication pass observation was conducted with LVN 3 for…

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 interview, the facility failed to store the drugs and biologicals in a safe manner. * An expired bottle of povidone iodine (medication used for skin disinfection) was observed in Medication Cart 1. * Multiple expired Covid-19 Antigen tests (a test used to check for the presence of the Covid-19 virus ) were stored in Medication room [ROOM NUMBER]. These failures had the potential to result in unsafe administration of medications. Findings: 1. On [DATE] at 1414 hours, an inspection of Medication Cart 1 was conducted with LVN 2. A bottle of povidone iodine prep solution had an expiration date of 1/22. LVN 2 verified the findings and stated it should have been discarded. 2. On [DATE] at 14:40 hours, an inspection of Medication room [ROOM NUMBER] was conducted with LVN 2. The following were observed: - one Covid-19 Antigen tests with an expiration date of [DATE], and - 10 Covid-19 Antigen tests with an expiration date of [DATE]. LVN 2 verified the findings and acknowledged the Covid-19…

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.