Denver North Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#1) of two residents reviewed out of 11 sample residents. Specifically, the facility failed to implement person centered interventions to address Resident #1's pattern of escalating behaviors. Findings include: I. Facility policy and procedure The Behavior Monitoring policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 2/11/25 at 4:23 p.m. It read in pertinent part, The purpose of behavior monitoring is to establish an accurate pattern of resident targeted behaviors as determined by the resident's history, evaluation, assessment. The goal is to determine appropriate behavior interventions such as counseling, behavior management plan including non-pharmacological interventions, and psychoactive medication management. When a resident displays targeted and/or inappropriate…

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

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Cutting boards were free from deep scratches and stains; -Frozen food thawing process was followed; and, -Beard restraints were worn in kitchen areas while preparing food. Findings include: I. Cutting boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, retrieved 1/16/24 from https://cdphe.colorado.gov/environment/food-regulations, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 1/3/24 at 8:29 a.m. revealed five large cutting boards and the cutting board on the serving line. There was one green, one blue, one red, one large white, and one yellow cutting board. All cutting boards 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 observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 14 of 40 resident rooms in six hallways. Specifically, the facility failed to ensure walls, floors, baseboards, doors and ceilings were properly maintained and rooms were free of trash and floors deep cleaned. Findings include: I. Initial observations Observations of the resident living environment were conducted on 1/8/24 at 9:18 a.m. revealed: room [ROOM NUMBER]: The wall next to the resident's bed had sticker residue from four large picture adhesive tape on the wall. The wood chair molding was missing a section approximately seven inches long by four inches wide. The closet door was off the rails and leaning against the wall. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The transition strip at the entrance door was missing which had approximately a one-fourth inch lip.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure five (#56, #34, #3, #45 and #128) of six residents were free from unnecessary psychotropic medications out of 27 sample residents. Specifically, the facility failed to: -Implement effective individualized behavior monitoring in the medical record and follow physician orders to determine the efficacy of psychoactive medications for Residents #56, #34, #3 and #128; -Track behaviors of sexual aggression for Resident #128; and, -Update behavior tracking to reflect an increase in an antipsychotic medication for Resident #45. Findings include: I. Facility policy The Behavior Monitoring policy, dated 3/10/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 8:42 a.m. It read in pertinent part: Specific behavior(s) documentation will be utilized to monitor residents and behaviors. Identify the potential cause of the behavior(s), Attempt to eliminate or decrease the behavior(s) through interventions, Document the specific and observable…

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

Based on observation and staff interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on the hand held shower in the shower on the 100 hall, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 1/8/24 at 9:18 a.m. revealed: The hand held shower head in the 100 hall shower room did not have a backflow prevention valve on it. The hand held shower was long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pan. II. Staff interview The maintenance supervisor (MS) was interviewed on 1/9/24 at 9:44 a.m. He said he was familiar with the backflow valve protocol. The MS stated the hand held shower should have a backflow prevention valve on. He said he would install one immediately.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure each resident was being screened for a mental disorder prior to admission or that residents identified with a mental disorder were evaluated to receive care and services in the most integrated setting to meet their needs for one (#9) of four residents reviewed out of 27 sample residents. Specifically, the failed failed to: -Notify the State Mental Health Agency Resident #9 had exceeded the 60 day convalescent preadmission screening and resident review (PASRR) period; and, -Submit a new PASRR to the State Mental Health Agency for Resident #9 to determine if a level II evaluation was needed. Findings include: I. Facility policy and procedure The PASRR (Pre-admission Screen and Resident Review) policy, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE]. It revealed in pertinent part, Provisional Approval: Provisional approvals permit nursing facilities (NF) to accept a resident without a full level II evaluation (mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of two (#45 and #128) of five residents out of 27 sample residents. Specifically, the facility failed to: -Notify the State Mental Health Agency of Resident #128 necessity for inpatient psychiatric hospitalizations; and, -Notify the State Mental Health Agency of Resident #45's suicide attempt and physical aggression towards others. Findings include: I. Facility policy and procedure The PASRR (Pre-admission Screen and Resident Review) policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 1/8/24. It revealed in pertinent part, If a resident's psychiatric status changes after admission, the social services staff are responsible for contacting the State Mental Health Agency via completion and submission of a PASRR level I screen and indicate the reason for referral as a change in mental health status or psychiatric diagnosis. Status…

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

Based on observation, record review and interviews, the facility failed to ensure one (#3) of six residents reviewed for medication administration received treatment and care in accordance with professional standards of practice out of of 27 sample residents. Specifically, the facility failed to ensure that Resident #3 was not administered an expired inhaler as identified by the manufacturer's directions. Findings include: I. Professional references According to the Centers for Disease Control (CDC) website, retrieved on 1/18/24 from https://www.cdc.gov/wtc/prescriptionsafety.html#:~:text=You%20should%20dispose%20of%20any,or%20misusing%20the%20medication%20intentionally. included the following recommendations, You should dispose of any unused or expired prescription medicine as soon as possible. Timely disposal of prescription medicine can reduce the risk of others taking the medication accidentally or misusing the medication intentionally. According to the Food and Drug Administration (FDA) website, retrieved on 1/18/24 from…

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 observations, record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve the ability to perform activities of daily living (ADLs) for one (#3) of two residents reviewed for ADLs out of 27 residents. Specifically, the facility failed to provide supervision, oversight, encouragement and cueing with personal hygiene for Resident #3. Findings include: I. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder bipolar type and major depressive disorder recurrent. The 7/28/23 minimum data set (MDS) assessment documented the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident required supervision to one person assistance with personal hygiene and dressing. The assessment documented no behaviors of refusals of care. II. Observations and interview On 1/3/24 at 10:05…

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 observations, record review and interviews, the facility failed to ensure three (#60, #25 and #3) out of 27 sample residents remained free of accident hazards and received adequate supervision to prevent accidents. Specifically, the facility failed to: -Assess Resident #60 and #25's bolstered mattresses to ensure they remained free of accident hazards; and, -Provide supervision to Resident #3, who was a supervised smoker. Findings include: I. Resident #60 A. Resident status Resident #60, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included dementia, depression and chronic systolic congestive heart failure. According to the 11/22/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had verbal behaviors toward others. The MDS revealed the resident had no falls since admission. B. Observations From 1/3/24 to 1/8/24 from 8:00 a.m.…

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 observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#33 and #62) of three residents reviewed for the use of supplemental oxygen of 27 sample residents. Specifically, the facility failed to: -Have an oxygen order in place for an individual requiring supplemental oxygen to include correct liter flow for Resident #33; and, -Ensure oxygen was provided as ordered for Resident #62. Findings include: I. Facility policy The Oxygen policy, dated 4/14/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 11:51 a.m., included, Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#45) of three residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 27 sample residents. Specifically, the facility failed to ensure Resident #45 who expressed suicidal ideations was assessed and provided psychosocial support. Findings include: I. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included schizophrenia. The 10/9/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The mood assessment showed the resident denied any symptoms of depression. B. Resident observation and interview On 1/3/24 at 10:00 a.m. the resident was interviewed in his room. He said he did not remember 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 record review, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers, for COVID-19. This had the potential to affect all 77 residents residing in the facility at the time of the survey. Specifically, the facility failed to ensure: -Rapid point-of-care (POC) tests for COVID-19 were consistently conducted and documented on staff prior to the start of their shift, based on the facility's county positivity rate and outbreak status; and -Polymerase chain reaction (PCR) testing was conducted on all staff based on the county positivity rate and outbreak status. Cross reference F888 (COVID-19 staff vaccination matrix) and F880 (Infection control). Findings include: I. Professional references The healthcare community transmission levels for the facility's county of residence, obtained from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels, were reviewed for 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 III. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the September2022 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, history of stroke, weakness on the right side, dysphagia (swallowing difficulty) and dementia with behavioral disturbance. The 8/4/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired, he was rarely understood, and a brief interview for mental status score was not conducted. He required extensive assistance for most activities of daily living (ADLs). B. Record review The code status for Resident #41 was not listed on the front page of the electronic medical record. The binder at the nurses station contained a paper copy of the MOST form for Resident #41. The form read no CPR for the resident and only selective treatments. The form was not signed by the resident. It was signed by a proxy physician on 3/10/21. The resident did not have a copy of advanced directives in his chart, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure six (#47, #27, #30, #41, #43, and #50) of eleven residents were free from unnecessary psychotropic medications out of 36 sample residents. Specifically, the facility failed to: -Identify and monitor targeted behaviors for psychotropic medications for Resident #47, #27, #30, #41, #43, and #50; and, -Ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #47, #27, #30, #41 and #43. Findings include: I. Facility policy and procedure The Psychopharmacological Medications policy and procedure,revised 1/10/19, was provided by the regional clinical resource (RCR) on 9/15/22 at 3:25 p.m. It revealed in pertinent part, A licensed nurse will review admission medication orders and ensure appropriate diagnosis for use of each medication from the primary care physician. If the information was not obtained prior to admission, the licensed nurse and/or social services director will make every…

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

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated; and, -Ensure holding temperatures of food were within the safe range. Findings include: I. Failure to ensure food was labeled and dated correctly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure 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 observations, record review and interviews, the facility failed to develop and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for three out of four units. Specifically, the facility failed to: -Ensure proper hand hygiene was offered to residents prior to meals; and, -Ensure proper wearing of masks for staff. Findings include: I. Hand hygiene A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene Guidance, reviewed 1/30/2020, retrieved on 9/20/22 from: https://www.cdc.gov/handhygiene/providers/guideline.html, read in pertinent part, The core infection prevention and control practices for safe care delivery in all healthcare settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an…

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

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including agency staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to obtain the vaccination status of other outside providers. The facility did not have the vaccination status for all of the outside providers. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. Cross-reference F886 (COVID-19 testing), and F880 (Infection control). Findings include: I. Record review Staff vaccination matrixes were provided by the facility. The vaccination matrix failed to ensure all staff and providers who provided resident care were listed on the vaccine matrix. -Review of the matrix provided by the facility failed to include medical providers, which included psychiatric physician (PSY) and two staff, one who scribed (SC) and a case…

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 observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for two (#3 and #274) residents of five residents reviewed for dignity out of 36 sample residents. Specifically, the facility failed to: -Ensure Resident #3 had the right to a dignified existence and the ability to exercise self-determination by neglecting to support and honor the resident's status as a transgender female; and, -Assist Resident #274 with the organization of his personal items. Two weeks after admission, the resident's television (TV) was not properly mounted and he was not able to use it. In addition, he was not offered any linens for his mattress, and slept on top of the uncovered mattress. Findings include: I. Facility policy and procedure The Dignity policy, revised February 2021, was provided by the regional clinical resource (RCR) on 9/15/22. It read in…

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 observations, record review, and interviews, the facility failed to provide necessary care and services for residents who were unable to carry out activities of daily living for two (#41 and #275) of six residents reviewed for activities of daily living of 36 sample residents. Specifically, the facility failed to: -Establish an effective communication system for Resident #41 in order to provide him with services; and, -Provide nail care to Resident #275. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs), Supporting policy, revised in 2018, was provided by the regional clinical resource (RCR) on 9/15/22. It read in pertinent part, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#274) out of 36 sample residents reviewed for fecal incontinence and constipation received appropriate treatment and services to maintain normal bowel function as much as possible. Specifically, the facility failed to follow bowel protocol for Resident #274 who was at risk for constipation. Findings include: I. Facility policy and procedure The facility policy and procedure for Bowel and Bladder management were requested at the time of the survey. It was not provided prior to the exit on 9/15/22. II. Resident status Resident #274, age [AGE], was admitted to the facility on [DATE]. According to the 9/3/22 computerized physician orders (CPO), diagnoses included human immunodeficiency virus (HIV), weight loss, chronic kidney disease, gastro-esophogeal reflux disease (GERD), anxiety, nausea, shortness of breath, malignant rectal cancer, malignant bladder cancer, and insomnia. The MDS assessment was not completed for this resident. The 9/7/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to establish a communication process with the hospice provider, including how the communication would be documented between the facility and the hospice provider for one (#274) resident reviewed for hospice care and services out of 36 sample residents. Specifically, the facility failed to collaborate with hospice for the development, implementation and revision of the coordinated plan of care for Resident #274. Findings include: I. Resident status Resident #274, age [AGE], was admitted to the facility on [DATE]. According to the 9/3/22 computerized physician orders (CPO), diagnoses included human immunodeficiency virus (HIV), weight loss, chronic kidney disease, gastro-esophogeal reflux disease (GERD), anxiety, nausea, shortness of breath, malignant rectal cancer, malignant bladder cancer, and insomnia. The MDS assessment was not completed for this resident. The 9/7/22 social services assessment revealed the resident was cognitively intact…

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.