Parkway Pavilion Health And Rehabilitation Center

8Based on review of the facility annual training for Nurse Aides, facility documentation and interview, the facility failed to ensure the required 12 hours Nurse Aide training was completed. The findings include: An interview with the DNS on 9/11/2024 at 12:30 PM indicated there had been Nurse Aide training but the Staff Development Nurse who was responsible for the training is no longer employed by the facility. The DNS also indicated s/he could not provide evidence of the facility's annual 12 hours of in-service hours for 2024 because/he could not locate the training.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, facility documents, review of facility policy and staff interviews for 4 of 6 residents reviewed for Medication Regimen Review and Unnecessary Medications ( Residents #6, #22 #65, and #103), the facility failed to ensure pharmacy recommendations were addressed by the physician timely. The findings included. 1. Resident #6 's diagnoses included unspecified psychosis, unspecified dementia, and depression. A quarterly MDS assessment dated [DATE] identified Resident #6 had severe cognitive impairment and required supervision or touching assistance for transferring from bed to chair. a. On 9/10/2024, a sample of pharmacy recommendations for Resident #6 was reviewed and identified the following: The pharmacy recommendation dated 9/30/23 indicated Resident #6 had two orders for Acetaminophen ( Tylenol), which may be considered duplicate therapy and recommended that one of the orders be discontinued. The pharmacy recommendation form did not contain a physician's response 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.

Based on observations of the Environment and staff interviews for 1 of 4 units for the East South wing, the facility failed to provide a homelike, clean and safe environment for Resident #89. The findings include: Observation of Resident #89's lower wall behind the bed during the initial facility tour on 9/04/24 at 10:47AM identified the window noted with a large area of chipped wall paint, detached floorboard panel with a brown- like substance on the lower half of the wall and the floor behind Resident #89's bed. Interview with Resident #89 on 9/04/24 at 10:47AM identified the lower wall behind the bed has been in this condition for some time and s/he reported it to staff members but could not recall exact names. Interview with the Director of Maintenance on 9/11/24 at 9:30AM identified s/he was not aware of the condition of the wall needing repair. The Director of Maintenance also indicated s/he does not participate in the monthly Environmental Rounds of the facility. The Director of Maintenance identified at the end of the interview that staff may have mentioned the wall 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 clinical record reviews, observation, and staff interviews, for 1 of 6 residents reviewed for abuse (Resident #110), the facility failed to protect a resident's right to be free from verbal abuse by a resident with a history of resident-to-resident altercations (Resident #6). The findings include: 1. Resident #6's diagnoses include unspecified psychosis, unspecified dementia, and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 as severely cognitively impaired and required supervision or touching assistance for transferring from bed to chair and for walking ten feet. A Resident Care Plan dated 5/7/2024 identified Resident #6 had a history of witnessed physical altercations with other residents including a prior roommate. The care plan indicated the altercations occurred on 2/22/2024 and on 5/7/2024. Interventions included separating the involved residents, social service follow-up, and psychiatry follow-up. 2. Resident #110 was admitted on [DATE] with 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 clinical record reviews, facility documents, review of facility policy and interviews for 2 of 6 residents (Residents #89 and # 106) reviewed for abuse, the facility failed to protect residents from abuse by not immediately removing an alleged staff member from the facility per facility policy. The findings included. 1. Resident #89's diagnoses included poly neuropathy, chronic pain, Type 2 diabetes mellitus, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #89 was cognitively intact. Resident #89's care plan dated 7/10/2024 indicated Resident #89 has chronic pain and requires pain medication. Interventions directed to observe adverse reactions with every interaction with the resident. The care plan dated 7/30/2024 indicated Resident #89 was noted to have accusatory behaviors towards staff, throwing items secondary to anger and prefers to stay in bed most of the time. Interventions directed to have 2 caregivers at all times and to provide psychiatric…

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 clinical record reviews and staff interviews for 1 of 4 sampled residents, (Resident #74) reviewed for Preadmission Screening and Resident Review (PASRR), and 1 sampled resident, (Resident #121) reviewed for hospitalization, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment coding for 1 of 3 ( Resident #79) residents reviewed for Respiratory Care, the facility failed to ensure the resident's utilization of oxygen was coded correctly on the MDS assesssment. The findings included: 1. Resident #74's diagnoses included schizophrenia and unspecified intellectual disabilities. The Notice of PASRR Level II Outcome dated 11/11/21 identified Resident #74 with diagnoses of severe mental illness/intellectual disabilities and noted the resident was approved without the need of specialized services. The Annual Minimum Data Set assessment dated [DATE] identified Resident #74 as severely cognitively impaired and required one person assist with activities of daily living and was not…

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 review of the clinical records, review of facility policy and interviews for 1 of 3 residents ( Resident #72) reviewed for Respiratory Care, the facility failed to ensure the care plan reflected the needs of the resident and for 1 of 2 residents ( Resident # 120) reviewed for hospice, the facility failed to develop a comprehensive care plan to address the resident's needs. The findings included: 1. Resident #72's diagnosis includes a muscle disorder with generalized muscle weakness, acute respiratory failure with hypoxia (low oxygen) and obstructive sleep apnea. The Registered Nurse ( RN) admission note dated 7/31/2024 at 5:03 PM indicated in part Resident #72 had a tracheostomy tube (Trach) capped as tolerated and utilized a non-mechanical ventilator (AVAPS) The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 as cognitively intact, tracheostomy (Trach) care and and noted use of a non-invasive mechanical ventilator. The care plan dated 8/12/2024 Resident #72 noted stage 1…

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 clinical record review, facility policy and staff interviews for 1 resident reviewed for edema (Resident #61), the facility failed to update/ revise the resident's care plan. The findings include: Resident #61 was admitted to the facility on [DATE]. Resident #61's diagnoses included Congestive Heart failure (CHF), cellulitis of the right lower limb and lymphedema. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #61 as cognitively intact. Resident #61 was transferred to the hospital on 7/2/2024 and readmitted to the facility on [DATE]. A physician's order dated 7/14/2024 directed to obtain a daily weight for CHF monitoring and to notify the physician if there was a gain of 2 pounds in 24 hours or 5 pounds gained in a week. The RCP dated 8/30/2024 indicated Resident #61 had a nutritional problem or the potential for a nutritional problem related to CHF and use of a diuretic (water pill). Interventions included: to restrict fluid intake and obtain laboratory work as ordered…

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 clinical record reviews, review of facility policy and interviews for 1 resident (Resident #50) reviewed for pain, the facility failed to follow up on the residents Ear, Nose and Throat (ENT) appointment per physician's order timely and for 1 resident ( Resident # 61) reviewed for edema, the facility failed to conduct weights per physician's orders and for 1 resident ( Resident # 120) reviewed for End of Life/ Hospice, the facility failed to follow the plan of care. The findings included: 1. Resident #50's diagnoses included chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD) and unspecified hearing loss. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 as cognitively intact and noted the resident required supervised set up assist with bed mobility, two persons assist with transfers. The Resident Care Plan dated 7/9/24 identified Resident #50 had a potential for pain related to general discomfort and a hearing impairment. Interventions directed 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.

Based on clinical record review and staff interview for 1 resident ( Resident # 19) reviewed for bowel management, the facility failed to consistently change the resident's bowel appliance. The findings include: Resident # 19's diagnoses included schizophrenia, Alzheimer's disease, dementia and dysphagia. The MDS 6/4/24 annual assessment identified the resident as moderately cognitively impaired and noted no functional limitation with upper extremities. Additionally, the assessment noted the utilization of a colostomy. The RCP 7/4/24 for require assistance with ADL. Intervention includes providing physical therapy 5 times a week and occupational therapy 4 times a week. The nurses note 9/4/24 at 5:05 PM identified that Resident # 19 notified the nurse that a nurse aide refused to assist her/him with his/her bowel appliance and the nurse aide also came in turned off the call bell light without seeing what s/he needed. A review of the Treatment Administration Records ( TAR) and Medication Administration Record ( MAR) for August 15, 2024 to 9/10/24 2024 failed to reflect when Resident #…

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 review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #65) reviewed for nutrition, the facility failed to re-weigh resident within 24 hours of a weight change per policy. The findings include: Resident #65 's diagnoses included dysphagia, chronic kidney disease, and gastrointestinal hemorrhage. The admission MDS assessment dated [DATE] identified Resident #65 as moderately cognitively impaired and required maximum assistance with showering, dressing, and indicated the resident was dependent for toileting. A physician's order dated 7/16/24 directed to provide a Consistent Carbohydrate Diet with no added salt, mechanical ground soft texture regular thin liquid consistency. The Resident Care Plan with a revision date of 7/26/24 identified the resident has a nutritional problem or potential for a nutritional problem related to end stage renal disease, GI issues and dysphagia. Interventions included providing diet as ordered, obtain a dietary…

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, clinical record reviews, review of policy and interviews for 1 of 3 residents ( Resident #72) reviewed for Respiratory Care, the facility failed to ensure supplies were available for a resident with specific respiratory needs in the event of an emergency and for 2 of 3 sampled residents ( Residents # 79 and Resident # 112) reviewed for respiratory care, the facility failed to ensure the resident's oxygen tubing was dated and labeled in accordance to facility practice. The findings include: 1. Resident #72's diagnosis includes a muscle disorder with generalized muscle weakness, acute respiratory failure with hypoxia (low oxygen) and obstructive sleep apnea. The Registered Nurse ( RN) admission note dated 7/31/2024 at 5:03 PM indicated in part Resident #72 had a tracheostomy tube (Trach) capped as tolerated and utilized a non-mechanical ventilator (AVAPS) The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 as cognitively intact, tracheostomy (Trach) care 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 review of the clinical record, facility documentation and interviews for 1 resident (Resident# 422) reviewed for Unnecessary Medication, the facility failed to promote the resident psychosocial well-being by when the resident missing property could not be located timely. The findings include: Resident #422 's diagnoses included hypertension, dysphagia and cognitive communication defect. The care plan dated 7/25/24 identified Resident #422 had psychosocial wellbeing problem related admission. Interventions include to give positive reinforcement and attempt to resolve conflicts. A physician's order dated 7/25/24 indicated to monitor for sudden changes in behaviors. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #422 was cognitively intact and requires require supervision/ touching assistance for bed mobility. A review of facility documentation identified on 8/4/24 Resident # 422 reported to staff s/he could not find his/her wallet but thought s/he had left her/his wallet with 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 clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #173) reviewed for hospice, the facility failed to ensure the provision of routine and emergency pain medication for a resident receiving end of life services/ Hospice. The findings include: Resident #173's diagnoses included pancreatic cancer and diabetes mellitus, type II and receiving end of of life services. The findings include: The Nursing admission assessment dated [DATE] identified Resident #173 was admitted from home, was alert and oriented, independent with self-care and did not report any pain. The facsimile Medication Order Report dated 6/4/23 received from the community hospice center identified Resident #173 had medications orders that included acetaminophen tablet 325 MG by mouth every 4 hours as needed for Pain/Elevated Temperature greater than 101 Do not exceed 3 GM in 24 hours, Morphine Sulfate (concentrate) solution 20 MG/ML. Give 0.25 ml by mouth every 3 hours as…

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 review of the clinical record, facility policy and interviews for 1 of 6 residents reviewed for Unnecessary Medication, the facility failed to order as needed (PRN) psychotropic medications for only 14 days. The findings include: Resident #22 's diagnoses included vascular dementia, hyperlipidemia and type 2 diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #22 as cognitively impaired and dependent on staff with eating, oral hygiene and bed mobility. The care plan dated 8/1/24 identified Resident #22 uses anti-anxiety medications related to restlessness. Interventions include to give anti-anxiety medications ordered by physician. Monitor and document side effects and effectiveness. A physician's order dated 8/21/24 directed to give 1 tablet (Lorazepam oral tablet 0.5MG) by mouth every 4 hours as needed for anxiety/restlessness for 30 Days. The Medication Administration Records indicated Resident #22 last received the Lorazepam on 9/7/24. Interview with 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 observations and staff interviews for 1 of 2 medication rooms and 2 of 3 medication carts reviewed for medication storage, the facility failed to ensure that medications were labeled appropriately and stored in a clean and sanitary environment. The findings include: 1. On 9/4/2024 at 11:05 AM observation of the East Medication Room and medication refrigerator with LPN #8. The following was observed the medication refrigerator appeared visibly soiled. There was brown, flaky residue on the back left side of the lower shelf where one box of Omeprazole oral suspension and three 150 ml bottles of Vancomycin oral solution were stored. There were two clear drawers under the bottom shelf that had brown and pink residue. Due to the sticky pink residue, the right side drawer was difficult to open as it was stuck to the lower portion of the refrigerator. The bottom shelf inside the refrigerator door also had pink, brown, and white residue. The inside of the door also had brown and pink residue on it. 2. The medication refrigerator also had a top freezer. The freezer was noted to 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 observations of the dumpster and interviews, the facility failed to properly dispose of garbage and refuse. The findings include: Observation made with the Dietary Director, Maintenance Director, and Environmental Director on 9/4/24 at 10:18AM of the dumpsters identified numerous debris left alongside of the dumpsters and facility which included a discarded mattress with a brown substance noted on the cover, multiple used gloves, discarded cigarette buds, plastic cups, bags, and bottles. On 9/4/24 at 10:18AM an interview with the Dietary Director identified the area was not well kept or cleaned and s/he was unsure of who was responsible for maintaining the area around the dumpsters. On 9/4/24 at 10:20 AM an interview with the Maintenance Director identified the dumpsters are emptied 2 times a week. The Maintenance Director also identified that's s/he was unsure of who was responsible for maintaining the area around the dumpsters. On 9/04/24 at 2:23 PM an interview with RN #1 identified all the staff were responsible for picking up around the dumpsters. and there is no…

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 review of facility documentation and interview, the facility failed to ensure QAPI meetings were conducted at least quarterly, and a Performance Improvement Plan (PIP) completed annually. The findings include: An interview with the Administrator, the DNS and RN #1 on 9/11/2024 at 2:33 PM identified they were unable to provide evidence of a QAPI meeting from October 2023 through February 15, 2024, and was unable to provide evidence that a PIP performed annually in 2022, 2023 or 2024. The Administrator indicated s/he was not at the facility at the time indicated therefore cannot answer why it was done. The Administrator since then the facility have conducted QAPI meetings almost every month and would be conducting a PIP in the near future. The facility policy Quality Assurance and Performance improvement (QAPI) Program indicated in part prioritizing identified quality issues based on risk of h arm and frequency of occurrence and determining which will become a focus of PIP's is an action step of the process.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, facility policy and staff interviews for 1 resident reviewed for 1 resident (Resident #72) reviewed for tracheostomy care, the staff failed to implement appropriate infection control techniques for enhanced barrier precautions for the resident. The findings include: Resident #72's diagnoses included Myotonic Muscular Dystrophy, acute respiratory failure, and muscle weakness. The admission Minimum Data Set assessment dated [DATE] identified Resident #72 as cognitively intact and required maximum assistance for toileting, showering, and dressing. A physician's order dated 8/30/24 directed to provide tracheostomy care two times daily. The Resident Care Plan dated 9/9/2024 identified the resident was on enhanced barrier precautions related to tracheostomy care. Interventions included for the staff to wear gown and gloves while caring for the resident and to follow facility policies for enhanced barrier precautions. Observed tracheostomy care on 9/9/24 at 10:15 AM 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 clinical record review, observations, review of facility policy and staff interviews for 1 of 3 residents (#72) reviewed for Respiratory Care, the facility failed to ensure licensed staff were trained to provide an emergency procedure for a resident requiring specialized care. The findings include: Resident #72's diagnosis includes a muscle disorder with generalized muscle weakness, acute respiratory failure with hypoxia (low oxygen) and obstructive sleep apnea. The Registered Nurse ( RN) admission note dated 7/31/2024 at 5:03 PM indicated in part Resident #72 had a tracheostomy tube (Trach) capped as tolerated and utilized a non-mechanical ventilator (AVAPS) The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 as cognitively intact, tracheostomy (Trach) care and and noted use of a non-invasive mechanical ventilator. The care plan dated 8/12/2024 Resident #72 noted stage 1 wound (non-blanchable redness) on the bridge of the nose. Intervention included: to assist/encourage…

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 review of clinical records, interviews, and facility documentation for one (1) of three (3) residents reviewed for elopement risk, (Resident #2), the facility failed to provide necessary monitoring and supervision for a resident that was identified as an elopement risk. The findings included: Resident #2 had diagnoses which included unspecified dementia and an anxiety disorder. A Minimum Data Set assessment dated [DATE] identified Resident #2 as severely cognitively impaired and required supervision with ambulation. A Resident Care Plan dated 4/15/24 identified Resident #2 was at risk for elopement with interventions that directed to have more frequent monitoring outdoors due to non-compliance with electronic bracelet due to self removal with every 15 minute checks in place. Review of Observation Worksheets identified Resident #2 was on 15 minute checks from 4/15/24 through 7/19/24. a) Review of a nurse's note dated 4/15/24 at 3:58 PM identified Resident #2 had exited the facility and proceeded to 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.

Based on a tour of the facility, the facility failed to ensure the door locks were properly functioning. The findings included: Observations conducted on 7/30/24 at 4:30 PM identified the door on TCU North unit leading outdoors, although alarmed, failed to engage the delayed egress, allowing exit from the building immediately without the delay of egress. Interview with the Director of Maintenance on 7/30/24 at 4:46 PM identified door locks and alarms were checked monthly per Facility Compliance Services standards of practice., and he was unsure why the delayed egress feature was non-functional. Review of the facility's Monthly Coded Door Inspection Log Sheets identified the facility doors were checked monthly in accordance with facility policy and that all door locks and alarms were properly functioning, with the last coded door inspection check completed on 7/23/24. The facility stated that they were placing a staff member at the door continuously until the door was fixed. Although requested, the facility was unable to provide a policy regarding door lock/safety checks.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure supervision was provided for a resident with wandering behaviors in accordance with physician orders. The findings include: Resident # 1 was admitted with diagnoses that included Alzheimer's disease, osteoporosis, and unsteadiness. The quarterly MDS assessment dated [DATE] identified Resident #1 had severely impaired cognitive skills, required limited assistance for bed mobility, and was independent for transfers and walking. The Resident Care Plan (RCP) dated 11/28/2023 identified Resident #1 had impaired cognitive function/impaired thought processes, was an elopement risk and was at risk for safety due to intrusive and constant behavior and wandering. Interventions directed to cue, re-orient, supervise as needed, and to keep Resident #1 in line of sight when wandering. A physician's order dated 11/19/2023 directed to keep…

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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for accidents, the facility failed to implement a plan of care for a resident who was a high risk for falls, required assistance with ambulation and frequently ambulated unassisted resulting in a fall with major injuries. The findings include: Resident #2 was admitted [DATE] to the facility with diagnoses that included pneumonia, Alzheimer's, anxiety and repeated falls. The admission assessment dated [DATE] identified Resident #1 was alert, confused and oriented to self only, was continent of bowel and bladder, required setup or clean up assistance for toileting, and required supervision/ assistance for toilet transfers. The care plan dated 10/4/23 identified Resident #2 had an activities of daily living (ADL's) self care performance deficit with interventions that included assistance of one with transfers, ambulation, and toileting. A Fall risk assessment…

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 clinical record review, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for accidents, the facility failed to provide adequate supervision to a resident who was assessed as a high fall risk and was impulsive with ambulation resulting in a fall with injury. The finding includes: Cross reference F-656 Resident #2 had diagnoses that included pneumonia, Alzheimer's, anxiety, and repeated falls. The admission assessment dated [DATE] identified Resident #1 was alert, confused and oriented to self only and required supervision/ assistance for toilet transfers. A Fall risk assessment dated [DATE] identified Resident #2 was at high risk for falling. The care plan dated [DATE] identified Resident #2 had an activities of daily living (ADL's) self-care performance deficit with interventions that included assistance of one with transfers, ambulation, and toileting. There was no specific care plan related to fall risk. A nursing note dated [DATE] at…

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 clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #20 and #87) reviewed for advance directives, the facility failed to ensure advance directive choices were reviewed with the resident or the resident's representative timely to ensure their choices were honored. The findings include: 1. Resident #20's diagnoses included Dementia. Resident #20 was admitted to the facility during 7/2021. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 had moderate cognitive impairment, was not receiving hospice services and did not have a life expectancy of less than six (6) months. Review of the clinical record identified Resident #20 had a Power of Attorney (POA), with a copy of the POA located in the chart. Review of the physician's orders from admission (7/2021) to [DATE] directed that Resident # 20's status was a full code. The social services assessment completed on [DATE] identified Resident #20's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility documentation review, and interviews for two sampled residents (Resident #33 and #58), reviewed for care and services, the facility failed to ensure floor mats in use were maintained in good condition. The findings include: 1. Resident # 33's diagnoses included dementia and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 had severe cognitive impairment and required maximum assistance of two staff for positioning. The Resident Care Plan (RCP) dated 11/19/2021 identified Resident #33 was at risk for falls. Interventions directed use of a floor mat on the floor on door side of the bed when Resident #33 was in bed. Intermittent observations of Resident #33 in bed on 1/31 and 2/1/2022 identified a large rectangular red floor mat was located on the floor next to Resident #33's bed, near the door side of the bed. The mat was observed to have multiple cracked, torn and ripped areas throughout the entire surface…

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 clinical record review, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #110) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment and the facility failed to ensure staff provided the resident with a meal timely. The findings include: Resident #110's diagnoses included dementia and heart failure. The Nursing admission assessment dated [DATE] identified Resident # 110 was confused, required assistance with ADLs due to generalized weakness related to recent hospitalization and required staff supervision for meals. Observations on 1/31/2022 at 8:45 AM identified Resident #110 was in bed with the head of his/her bed rolled up. Resident #110 had his/her eyes closed and did not respond when greeted by surveyor - appeared to be sleeping. The meal tray contained a plate with the cover still over the food, the flatware was clean, and there were two (2) cups containing liquids with the cups covered with 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 review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #117) reviewed for urinary catheter, the facility failed to ensure continued use of an indwelling catheter was assessed timely. The findings include: Resident #117's diagnoses included obstructive and reflux uropathy. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #117 was cognitively intact and required extensive staff assistance for toileting. Resident #117 was further identified to have an indwelling catheter and a trial of a toileting program had not been attempted on admission. The Resident Care Plan (RCP) dated 11/13/21 identified Resident #117 had an indwelling catheter and was at risk for infection and/or complications. Interventions directed to providing catheter care daily, observe for pain/discomfort due to catheter and signs/symptoms of UTI, change the drainage bag monthly and cover the bag for privacy/dignity. 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 observations, facility policy review, and interviews for facility medication storage, the facility failed to ensure the safe storage of prescribed medications in their original packaging. The findings include: 1. Observation of LPN #5's medication cart on 2/3/2022 at 2:00 PM identified in every drawer except the locked narcotic box drawer, a total of 74 unidentifiable tablets scattered around in open view mixed throughout the bottom of each drawer. Interview with LPN #5 on 2/3/2022 at 2:10 PM identified medication should be stored in their respective bottles/containers with proper labeling. Any medications that are found not inside their respective bottles/containers must be wasted with another nurse for proper medication disposal. LPN #5 identified staff should clean their medication carts at the end of each shift and ensure no loose medication are identified within the cart. 2. Observation of LPN #6's medication cart on 2/3/2022 at 2:15 PM identified in every drawer except the locked narcotic box drawer, a total of 12 unidentifiable tablets scattered around in open view…

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, facility documentation, review facility policy review and interviews, the facility failed to ensure the kitchen was maintained in a clean and well-maintained manner, and the facility failed to ensure a fan used in the kitchen was cleaned timely, and the facility failed to ensure foods were stored in accordance with accepted practices, and the facility failed to ensure kitchen equipment was maintained in good repair, and the facility failed to ensure temperature logs were completed timely. The findings include: Tour of the facility kitchen with the Food Service Director (FSD) on 1/31/2022 at 7:00 AM identified approximately ten (10) missing floor (vinyl-like) tiles on the hallway leading into the kitchen with a large piece of cardboard over the floor where the tiles were missing. Additional observations of the hallway identified the right-side wall (back of the wall from the kitchen) had many areas of chipped and missing paint over the lower six (6) inches of the wall. Observations inside the kitchen identified a puddle of water was observed on the floor near…

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 clinical record review, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #110) reviewed for a change in condition, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment was documented timely for a resident with an identified change in condition. The findings include: Resident #110's diagnoses included dementia and heart failure. The Nursing admission assessment dated [DATE] identified Resident # 110 was confused, required assistance with ADLs due to generalized weakness related to recent hospitalization and required staff supervision for meals. Observations on 1/31/2022 at 8:45 AM identified Resident #110 was in bed with the head of his/her bed rolled up. Interview with LPN #4 on 1/31/2022 at 9:45 AM identified Resident #110 had a change in condition and was unresponsive. LPN #4 indicated that she had notified the physician. Clinical record review on 2/1/2022 failed to identify an RN…

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, facility documentation review, facility policy review, and interviews for facility infection control review, the facility failed to ensure signage was posted timely to alert staff and visitors of a COVID-19 outbreak in the facility. The findings include: Observations on 1/31/2022 at 6:00 AM failed to identify signs were posted at the facility entrance to identify a COIVD-19 outbreak in the facility. Interview with the Administrator on 1/31/2022 at 9:30 AM identified there were currently nineteen (19) residents in the facility that were currently COVID-19 positive and on isolation precautions. Additional observations on 2/1 at 8:40 AM, and 2/2/2022 at 8:35 AM failed to identify signs were posted at the facility entrance to identify a COIVD-19 outbreak in the facility. Interview with the ADNS and RN #6 on 2/3/2022 at 10:16 AM identified although there should be signage posted at the main entrance/front door to alert visitors and staff of the COVID-19 outbreak in the facility, they were unable to demonstrate signs were posted. Observation of the main facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, a review of the facility documentation and staff interviews for one of three sampled residents reviewed for ambulation (Resident #20 and Resident #89), the facility failed to provide documentation and/or failed to ambulate the resident as per rehabilitation recommendations and/or as directed in the physicians orders. The findings include: a. Resident #20 was admitted to the facility on [DATE] with diagnoses that included dementia, heart disease, hypertension and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition and required extensive assistance with transfers and walking in corridors. A care plan dated 5/13/19 identified Resident #20 has an activities of daily living (ADL) self-care performance deficit, was unable to complete ADL tasks independently, and required individualized interventions to improve function secondary to weakness and impaired cognition. Interventions directed to provide assistance when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, staff interviews, a review of facility documentation, and a review of facility policy, for three of five residents (Resident #11, #36, #109) reviewed for immunizations, the facility failed to ensure documentation and/or the refusal of immunizations. The findings include: a. Resident #11 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance and chronic kidney disease. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #11 with severe cognitive impairment, the pneumococcal vaccination was not up to date and Resident#11 was offered the pneumococcal vaccine but declined its administration. Review of facility immunization report identified Resident #11 refused the first dose of Pneumovax, however the documentation failed to identify a date or time. In addition the refusal form could not be located, and/or documentation failed to identify that Prevnar 13 was requested for consent. Interview with 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 an observation, a review of the clinical record, a review of facility documentation, staff interviews and a review of facility policy, for one resident (Resident #34) reviewed for abuse, the facility failed to provide freedom from abuse, neglect, or exploitation. The findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, brain injury, major depressive disorder, anxiety disorder, traumatic brain injury and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident # 34 with severe cognitive impairment, incontinent of bowel and bladder, total dependence for transfers with a two person assist. The care plan dated 5/31/19 identified limited physical mobility related to weakness, was at risk for falls, and suffered from dementia with depressive features. Interventions included to allow the resident to perform tasks at his/her own rate, do not rush the resident and encourage independent activity. The care…

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 clinical record reviews, review of facility documentation and interviews for one sampled residents (Resident #174) who was reviewed for activity of daily living, the facility failed to ensure that the resident received showers and/or failed to document that the showers were offered, given and /or refused by the resident who was dependent on staff for care. The findings include: Resident #174's diagnoses included diabetes mellitus, heart failure, rhabdomyolysis, and acute respiratory failure. The admission nurse's note dated 9/7/18 identified Resident #174 was admitted at 8:45 PM via ambulance on a bariatric stretcher from the hospital. The nurse's note dated 9/8/18 at 4:15 AM identified Resident #174 was alert and oriented to person, place, time, and situation. The Resident Care Plan dated 9/8/18 identified Resident#174 had a self-care deficit secondary to generalized weakness and difficulty ambulating. Interventions indicated the resident required assistance of two (2) with bathing. The admission…

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 clinical record reviews, staff interviews, a review of facility documentation for one of five sampled residents (Resident # 118) reviewed for accidents, the facility failed to conduct preventative maintenance to ensure equipment was functional and/or safe. The findings include: Resident # 118's diagnoses included morbid obesity, pyogenic arthritis, orthopedic aftercare right knee, muscle weakness, and difficulty walking. Physician's orders dated 2/1/19 identified weight bearing as tolerated to the right lower extremity. The Resident Care Plan (RCP) dated 2/1/19 identified Resident # 118 required assistance with activities of daily living. Interventions directed to assist with hygiene as needed The MDS assessment dated [DATE] identified Resident #118 was cognitively intact and required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Review of the facility documentation dated 3/14/19 at 11:25 AM indicated Resident #118 had finished…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, an observation, staff interviews and a review of the facility policy for one of four residents reviewed for nutrition (Resident # 3), the facility failed to ensure the resident received a nutritional supplement and/or failed to conduct a speech evaluation as directed in the physician orders. The findings include: Resident # 3's diagnoses included feeding difficulties, difficulty swallowing, cerebral infarction, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment and required extensive assistance of one person to eat. The Resident Care Plan dated 8/6/19 identified Resident # 3 is at risk for nutritional decline. Interventions included to provide four ounces of ensure pudding twice a day, to provide a sandwich with lunch and to provide speech therapy as needed. a. A review of the clinical record identified a weight of 135.4 pounds on 5/2/19 and a weight of 126 pounds on 6/1/19 (a 6.94% weight loss in one month)…

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, staff interviews and a review of the facility policy, the facility failed to accurately label medications and/or failed to ensure the medication refrigerator was free from employee food items. The findings include: a. Observation on 08/08/19 at 8:50 AM identified one medication cart contained two opened resident specific containers of Latanoprost eye drops absent the identification of the date the medication was opened. Interview with LPN #2 identified this medication was typically administered by the evening nurses, and they should have placed an open date on them. Interview with RN #3 on 8/7/19 at 9:34 AM identified medications that required an expiration date should be dated directly on the medication bottle when it was opened. The facility Medication administration policy identified the nurse shall place a date opened sticker on the medication if one was not provided by the dispensing pharmacy. b. Observation of the medication room [ROOM NUMBER]/7/19 9:00 AM identified one unlabeled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, staff interviews, a review of the facility documentation, and a review of the facility policy, for one resident (Resident # 115), reviewed for intravenous therapy, the facility failed to consistently document the administration of a medication, and/or consistently document the assessment of a Peripheral Inserted Central Catheter (PICC) line. The findings include: Resident # 115 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes mellitus with a foot ulcer. The admission Minimum Data Set (MDS) dated [DATE] identified intact cognition, at risk for the development of a pressure ulcer, the identification of an infected foot ulcer, and was receiving antibiotics via a PICC line in the right antecubital space. A physician's order dated 8/1/19 directed to administer 2 Grams of Cefazolin intravenous (IV) every 8 hrs with a completion date of 8/29/19. Review of the medication administration record dated 8/1/19 through 8/7/19 identified 2 doses of…

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