Southport Center For Nursing & Rehabilitation Llc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #77) reviewed for indwelling catheter, the facility failed to ensure care according to professional standards for a resident who refused removal of an indwelling catheter over 5 months, that was ordered to be removed after 7 days. The findings include: Resident #77 was admitted to the facility in September 2021 with diagnoses that included urinary tract infection, chronic kidney disease, and acute candidiasis of the vulva and vagina.The quarterly MDS dated [DATE] identified Resident #77 had intact cognition, required maximal assistance for toileting hygiene, was dependent for bathing, required supervision for toilet transfers. Resident #77 was occasionally incontinent of urine, was frequently incontinent of bowel, was at risk for developing pressure ulcers/injuries, and had no pressure ulcer.The care plan dated 1/5/25 identified Resident #77 refused showers and bedding changes, contributing 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #100) reviewed for non-pressure ulcers, the facility failed to ensure hand hygiene was performed when required during the treatment of wounds. The findings include: Resident #100 was admitted to the facility in April 2023 with diagnoses that included lymphedema and acute kidney injury, and hypertension.The annual MDS dated [DATE] identified Resident #100 had intact cognition, required maximum assistance for dressing, putting on footwear, and personal hygiene. Additionally, Resident #100 has 2 venous or atrial ulcers present.The care plan dated 5/20/25 identified Resident #100 has venous ulcers to his/her bilateral lower extremities. Interventions included providing wound treatments as ordered and wrapping bilateral legs with compression socks.A vascular consult dated 6/17/25 directed compression stockings and a venous ultrasound. The physician identified the resident is wheelchair bound…

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, facility policy, and interview, the facility failed to ensure that a nurse aide was provided at least 12 hours annual in-service education, and competency evaluations were completed at least annually. The findings include: A review of education and in-service documentation for 2023, 2024, and 2025 failed to identify education and competencies had been completed for NA #14, who began employment at the facility on 12/5/22.Interview with LPN #1 on 7/30/25 at 7:15 AM identified she worked in a dual role as the staff development and infection control nurse. LPN #1 identified that the DNS and ADNS provided assistance to help her with staff development as they were able, but education was done as time allowed. LPN #1 identified that other than the actual in-service sign-in-sheets and competency packets, she did not have any tracking mechanisms to determine which staff required updated annual competencies or in services, or if all nurse aides in the facility had completed the required 12 hours of in-service training annually.Interview with the ADNS…

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, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure staff followed up with a consulting physician office timely in accordance with hospital discharge directions. The findings include: Resident #1 had a diagnosis of malignant neoplasm of the left breast. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview of Mental Status (BIMS) score of five (5) indicating severely impaired cognition and required assistance with Activities of Daily Living (ADLs). The Resident Care Plan (RCP) dated 2/26/2025 identified a diagnosis of cancer. Interventions directed to monitor for adverse effects if receiving chemotherapy or radiation. Hospital Discharge summary dated [DATE] directed to contact Resident #1's oncology office two (2) weeks post discharge for Stage 4 left breast cancer. No appointments were listed on the discharge summary. The nursing admission note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from physical mistreatment. The findings include: Resident #1's diagnoses included schizoaffective disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and was maximal assistance with all ADLs. The Resident Care Plan (RCP) dated 5/31/2024 identified Resident #1 exhibited behaviors as evidenced by being verbally/physically abusive, refusal of care, and aggression related to psychiatric conditions. Interventions directed approach resident in a calm and consistent manner, monitor for changes in mood/behavior and report to the physician, and to provide resident with the opportunity to express feelings through one-to-one and group visits. The facility incident report identified on 7/10/2024 at 6:00 PM identified…

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 fifteen (15) of nineteen (19) residents (Resident #7, #8, #9, #11 , #12. #13,#14, #16, #18, #19, #20, #22, #23, #24 and #25) who have a history of substance abuse disorder and receive methadone treatment, the facility failed to ensure the residents had orders for Narcan (an opiate overdose reversal medication) administration. The findings include: 1. Resident #7 was admitted to the facility with diagnoses that included metabolic encephalopathy and opioid dependence. The care plan dated 9/21/23 identified Resident #7 had a history of substance abuse with interventions that included to offer the option of attending the substance abuse group, interdisciplinary team and provider evaluation of leave of absence request, nursing support as needed and monitor for signs and symptoms of opioid overdose. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #7 had moderately impaired cognition and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 6 residents (Resident #3, #7, #8) reviewed for resident to resident altercations, the facility failed to create and implement interventions for residents after resident to resident abuse allegations. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and anxiety. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition, had verbal behavioral symptoms directed towards others, and required supervision with set up help on for activities of daily living (ADL's). The care plan dated 8/17/23 identified Resident #3 had behavioral symptoms with interventions included to encourage the resident to seek the assistance of staff when in challenging situations, social service to help deescalate upsurging behavior and to create a behavior modification plan through psychiatric services. Review of the accident 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, facility policy, and interviews for four (4) of six (6)residents, (Resident #3, #4, #7, #8), reviewed for resident to resident altercations, the facility failed to document social services visits for residents after resident to resident altercations. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included dementia with behavioral disturbance and anxiety. The quarterly MDS dated [DATE] identified Resident #3 had severely impaired cognition, had verbal behavioral symptoms directed towards others, and required supervision with set up help on for activities of daily living (ADL's). The care plan dated 8/17/23 identified Resident #3 had behavioral symptoms with interventions that included to encourage the resident to seek the assistance of staff when in challenging situations, social service to help deescalate upsurging behavior and to create a behavior modification plan through psychiatric services. Review of the…

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

Based on review of facility documentation, facility policy and interview the facility failed to ensure the resident council was provided responses, actions and rationale regarding their concerns. The findings include: Review of the resident council meeting minutes from April 2022 through November 2022 identified repeated concerns related to the food taste/quality, temperature, menus, and variety for 5 consecutive months (April, May, June, July, and August 2022). The October and November 2022 resident council minutes indicated residents expressed housekeeping concerns, and in July, August, and September 2022 the residents voiced missing belongings and laundry concerns. The resident council minutes and facility documentation failed to reflect attempts or steps by the facility staff to address and resolve the resident's concerns related to food taste/quality, temperature, menus, and variety, housekeeping, missing belongings and laundry concerns. During the resident council interview on 11/10/22 at 10:30AM with 12 residents who regularly attend and participate in the monthly 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 observation, review of the clinical record, facility documentation, facility policy, and interviews the facility failed to ensure resident rooms and other living areas were clean and well maintained and for Resident #67, the facility failed to ensure the wheelchair arm rests were in good repair. The findings include: 1. Observations on 11/8/22 at 11:50 AM through 12:42 PM, and on 11/10/22 at 1:00 PM through 2:05 PM, and on 11/15/22 at 2:34 through 2:51 PM with the Administrator identified the following: a. Damaged, chipped and/or marred bedroom walls on A wing in rooms 102, 103, 106, 109, 110, 111, 112, 113, 114, 117, 118, dining room, nurses station, and the hallway, on B wing in rooms 222, 230, 236, 237, 238, clean utility room, and the hallway, on C wing in rooms 339, 340, 341, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 355, 356, 357, the nursing station, and the hallway, on D wing in rooms 401, 405, 407, 408, 410, 411, 412, 414, 415, 416, shower room, and the dining room. b. Damaged, rusty,…

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, review of facility documentation, facility policy, and interviews the facility failed to ensure the walk-in refrigerator and freezer were maintained at the proper temperatures. The findings include: 1. Observation with the Director of Dietary on 11/8/22 at 10:20 AM identified some items in the freezer were noted to have chucks of ice oh them and there were chunks of ice on the floor. Three boxes on the bottom shelf had water lines halfway up the boxes. The Director of Dietary indicated that would occur when items defrost and then freeze again. A box was partially torn open and the item inside was covered with ice. The Director of Dietary indicated that item would have to be discarded and indicated he was aware the freezer door did not close properly. The freezer temperature was noted to be negative 4 degrees. Interview with the Director of Dietary on 11/10/22 indicated the freezer door was adjusted and now it is closing until they get the new part. 2a. Observation with the Director of Dietary of the Residents Nourishment refrigerator on Unit A on 11/10/22 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.

Based on observations, review of facility documentation and interview the facility failed to maintain an adequate pest control program. The findings include: Tour of the facility on 11/8/22 at 11:30 AM - 1:00 PM, and 11/10/22 at 12:55 PM - 2:15 PM identified numerous winged flying black insects were observed. Additionally, on 11/15/22 at 2:34 PM - 2:51 PM with the Administrator and RN #11 identified numerous winged flying black insects were observed. Winged flying black insects were noted in the following areas on bedroom walls, bathrooms, hallways, shower rooms, and the nourishment rooms. A wing in resident rooms, hallway, dining room, and the nourishment room. B wing in resident rooms, hallway, shower room, dining room, and the nourishment room. C wing in resident rooms, hallway, shower room, dining room, and the nourishment room. D wing in resident rooms, hallway, and the nourishment room. Review of the pest control invoice dated 11/2/22 at 7:24 AM identified (this was an add on trouble call ticket to check the B wing for fruit flies). Services was performed and a number 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.

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 5 residents (Resident #66) reviewed for dignity, the facility failed to ensure resident was treated in a dignified manner. The findings include: Resident #66 was admitted to the facility in September 2022 with diagnoses that included pain in the right hip, chest pain, chronic gout, and diabetes. The admission MDS dated [DATE] identified Resident #66 had intact cognition and required total 2-person assistance with transfers, and personal hygiene. Physician's orders dated November 2022 directed to provide 2- person assistance with bed mobility and utilize a hoyer lift for transfers. Interview with Resident #66 on 11/8/22 at 12:27 PM identified that on Sunday 11/6/22, a special day for him/her, during the 3:00 PM - 11:00 PM shift he/she was on the phone having a conversation when a nurse aide told him/her to (get off the phone if he/she wanted to get in bed). The nurse aides name was not provided. Resident #66…

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 2 of 2 residents (Resident #72 and 81) reviewed for care planning, the facility failed to ensure that the residents were invited to the care plan conference. The findings include: 1. Resident #72 was admitted to the facility in December 2021 with diagnoses that included pneumonia, covid-19, and acute kidney failure. The annual MDS dated [DATE] identified Resident #72 had mildly impaired cognition and required assistance with transfers, dressing, and personal hygiene. The care plan dated 8/24/22 identified to initiate a person-centered care plan that includes objectives to meet the residents medical, nursing, mental, and psychosocial needs. The care plan meeting signature sheet dated 8/24/22 identified although the residents POA attended via phone, the resident did not attend the meeting. A social work progress note, written by SW #1 dated 11/7/22 at 8:48 PM identified a quarterly care plan meeting was held on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #66) reviewed for choices, the facility failed to ensure resident choices were accommodated when the resident requested to go to bed and staff did not assist the resident for 4 hours. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included pain in the right hip, chest pain, chronic gout, and diabetes. The admission MDS dated [DATE] identified Resident #66 had intact cognition and required total 2-person assistance with transfers, and personal hygiene. Physician's orders dated November 2022 directed to provide 2- person assistance with bed mobility and utilize a hoyer lift for transfers. Interview with Resident #66 on 11/8/22 at 12:27 PM identified approximately 2 weeks ago, after he/she returned to his/her room from smoke break at 4:00 PM, he/she put the call light on and requested to go to bed. Resident #66 identified that a nurse aide told…

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 facility documentation, facility policy and interviews for 2 residents (Resident #39 and 53) reviewed for personal funds, the facility failed to ensure the residents' had ready access to their personal funds managed by the facility. The findings included: 1. Resident # 39's diagnoses included chronic kidney disease and diabetes. The quarterly MDS 10/10/22 identified Resident #39 had a moderately impaired cognition, utilized a rolling walking. Interview on 11/9/22 at 9:53 AM with Resident #39 identified that he/she had no ability to access his/her funds the facility managed on the weekends. Review of the facility authorization and agreement to handle resident funds, signed by Resident #39 on 10/15/21, identified Resident #39 had a resident fund account managed by the facility with a $60.00 monthly allowance, and that Resident #39 would receive a statement at least quarterly. 2 Resident # 53's diagnoses included diabetes. The annual MDS dated [DATE] identified Resident #53 had intact cognition.…

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 facility documentation, facility policy and interviews for 1 residents (Resident 53) reviewed for personal funds, the facility failed to ensure the residents' received quarterly statements from their personal funds account managed by the facility. The findings include: Resident # 53's diagnoses included diabetes. The annual MDS dated [DATE] identified Resident #53 had intact cognition. Interview with Resident #53 on 11/8/22 at 11:44 AM identified that the facility has been managing his/her personal funds for the last 3 or 4 months but he/she had never gotten a statement. Review of the facility authorization and agreement to handle resident funds, signed by Resident #53 on 7/13/22, identified that the resident had a resident fund account managed by the facility with a $75.00 monthly allowance and that Resident #53 would receive a statement at least quarterly. Interview with the Administrator on 11/10/22 at 11:37 AM identified the facility only provides statements for resident funds account on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #600) reviewed for abuse, the facility failed to report an allegation of verbal abuse to the state agency in accordance with established timeframes and facility policy. The findings include: Resident #600 was admitted to the facility in April 2022 with diagnoses that included traumatic compartment syndrome of right upper extremity, chronic pain due to trauma, and asthma. The quarterly MDS dated [DATE] identified Resident #600 had intact cognition and required supervision with personal hygiene and eating. A grievance form dated 10/7/22 identified Resident #600 reported that he/she asked NA #6 to warm up his/her food, and NA #6 opened the container before placing it in the microwave. Resident #600 indicated an argument started between him/her and NA #6. Resident #600 reported that NA #6 started yelling at him/her and told him/her to shut up. The grievance form further identified 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #600) reviewed for abuse, the facility failed to thoroughly investigate an allegation of verbal abuse. The findings include: Resident #600 was admitted to the facility in April 2022 with diagnoses that included traumatic compartment syndrome of right upper extremity, chronic pain due to trauma, and asthma. The quarterly MDS dated [DATE] identified Resident #600 had intact cognition and required supervision with personal hygiene and eating. A grievance form dated 10/7/22 identified Resident #600 reported that he/she asked NA #6 to warm up his/her food, and NA #6 opened the container before placing it in the microwave. Resident #600 indicated an argument started between him/her and NA #6. Resident #600 reported that NA #6 started yelling at him/her and told him/her to shut up. The grievance form further identified the resolution was NA #6 was removed from the assignment and provided…

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 interview for 3 of 4 residents (Resident #39, 72 and 75) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure the resident was referred to the appropriate state-designated authority for Level II PASARR evaluation and determination after a newly evident or possible serious mental disorder was identified. The findings include: 1. A PASARR Level 1 screen dated 9/27/21 identified Resident #39 had a diagnosis of mild or situational depression and had no diagnosis of dementia. The Level I outcome was to refer for a Level II onsite. A level II evaluation must be conducted. A PASARR summary of findings dated 9/30/21 identified Resident #39 had a diagnosis of depression and poly substance abuse which requires routine follow up with a mental health professional and a psychiatric medication regimen including Bupropion, Zyprexa, and Trazodone. Effective 9/30/21, Resident #39 was Level II approved…

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 resident (Resident #67) reviewed for accidents, the facility failed to ensure the plan of care was updated after a fall. The findings include: Resident #67 was admitted to the facility with diagnoses that included diabetes and chronic pain. A reportable event form dated 7/31/22 at 9:40 AM identified Resident #67 fell forward while trying to transfer independently and hit his/her face on the overbed table and sustained a fracture of the right mandible. The quarterly MDS dated [DATE] identified Resident #67 had intact cognition and required supervision for dressing, eating, toilet use, personal hygiene, and transfers. Additionally, Resident #67 does not ambulate and uses the wheelchair for locomotion in room and on unit. Resident #67 required supervision (oversight and cueing) for transfers, had 1 fall with injury and 1 fall with major injury of a bone fracture. A reportable event form dated 10/13/22 (not timed)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #67 was admitted to the facility with diagnoses that included diabetes and chronic pain. The quarterly MDS dated [DATE] identified Resident #67 had intact cognition and required supervision for dressing, eating, toilet use, personal hygiene, and transfers. Additionally, Resident #67 does not ambulate and uses the wheelchair for locomotion in room and on unit. Resident #67 required supervision (oversight and cueing) for transfers, had 1 fall with injury and 1 fall with major injury of a bone fracture. The care plan dated 11/8/22 identified a history of falls with interventions that included add dycem on wheelchair, check wheelchair brakes and instruct resident on proper use. Pharmacy medication review. The care plan failed to address the falls on 7/31/22, 10/13/22 and 10/17/22. Reportable event forms dated 7/23/22 at 4:25 AM, 7/31/22 at 9:40 AM and 10/13/22 identified Resident #67 had unwitnessed falls. On 7/23/22 at 4:25 AM and 7/31/22 the resident hit his/her head. Review of the clinical record…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #81) who requested to be seen by the eye doctor, the facility failed to ensure the resident was seen by the eye doctor. The findings include: Resident #81 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, hypertension, and chronic pain. A physician's order dated 11/19/21 directed to have a visual acuity screening every 2 years for appropriate residents. The admission MDS dated [DATE] identified Resident #81 had intact cognition, had adequate vision and could see fine details such as regular print in newspapers or books. Resident #81 did not need corrective lenses. The care plan dated 8/24/22 identified Resident #81 had good vision with no glasses. The nurse's note dated 9/23/22 at 10:55 PM identified Resident #81 had requested to be seen by the eye doctor. The morning nurse to follow up with scheduling. Review of the vision form list dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents, (Resident #65), who was at risk to develop pressure ulcers, the facility failed to ensure the air mattress (weight based air mattress) was set accurately to the residents weight. The findings include: Resident #65 was admitted to the facility in June 2022. Diagnoses included osteoporosis, diabetes and prostate cancer. The care plan provided, dated 6/8/22, identified Resident #65 had actual skin impairment and the potential for skin impairment. Interventions included pressure relieving mattress if appropriate. The quarterly MDS dated [DATE] identified Resident #65 had short and long term memory problems, severely impaired cognition, required total 2-person assistance with bed mobility, transfers, dressing toilet use, was always incontinent of bowel and bladder, was at risk to develop pressure ulcers and weighed 127 lbs. Intermittent observations during the survey on 11/8, 11/9 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 policy and interview for 1 resident (Resident #43) reviewed for a specialized treatment and on a fluid restriction, the facility failed to ensure fluid intake was consistently monitored. The findings include: Resident #43's diagnoses included end stage renal disease, hypertension, heart failure and depression. The care plan dated 9/27/22 identified Resident #43 was at risk for complications related to alteration in renal function resulting from end stage renal disease. Interventions included to maintain fluid restriction as ordered by the physician and monitor intake and output (I & O). The quarterly MDS dated [DATE] identified Resident #43 had severely impaired cognition, required supervision with eating after set up and was receiving dialysis treatments. The physician's order dated 10/31/22 directed dialysis 3 days a week every Tuesday, Thursday and Saturday, and fluid restriction 1000 ml; nursing: 280mls per day; dietary: 720mls per day. Review of the I & O…

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, review of the clinical record and facility policy for 1 unit, the facility failed to ensure the medication room was locked when unattended. The findings include. Observation on 11/10/22 at 6:00 AM, on C unit, identified LPN #2 was in the hallway by room [ROOM NUMBER] at the medication cart with an ear bud in her right ear. The C unit medication room, approximately 30 - 40 feet away from LPN #2 behind the nurse's station and around the corner was unattended and unlocked with over-the-counter medications on the counter. There were no licensed nurses near the nurse's station or unlocked medication room. Surveyor was unable to see LPN #2 from the medication room door. A resident was across from the nurse's station in the dining room. Interview with LPN #2 on 11/10/22 at 6:24 AM indicated she was passing medications when earlier a nursing assistant had asked for a colostomy bag so she had gone into the medication room and must have forgotten to lock it when she exited. LPN #2 indicated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #39 and 81) reviewed for dental services, the facility failed to ensure a dental referral was made timely when dentures were identified as missing and failed to provide dental services to a resident who had complaints of dental pain. The findings include: 1. Resident #39 had diagnoses that included chronic kidney disease, diabetes and depression. A Consent for Dental Services in a Nursing Home form identified verbal consent by resident was given on 1/19/22 and the form signed on 7/14/22. A clinical notes document dated 1/19/22 identified Resident #39 requested to be seen for loose dentures. Has full upper dentures (FUD), and full lower dentures (FLD) that were about 1 year old and were very loose. A dental note dated 2/18/22 identified resident complaining of sore spot on lower full denture. FLD adjusted, and resident says it feels better. Resident complains that dentures…

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, review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #16) reviewed for hydration, the facility failed to provide fluids/drinks, consistent with the resident requests. The findings include: Resident #16 was admitted to the facility in May 2015. Diagnoses included history of urinary tract infections and urinary retention with the use of an indwelling catheter. The annual MDS dated [DATE] identified Resident #16 had intact cognition, required total assistance with transfers and toilet use, was independent with eating after set up and had an indwelling catheter. The care plan dated 9/14/22 identified Resident #16 was at risk for dehydration due to dementia, history of dysphagia or thickened fluids and dietary restrictions. Interventions included the resident would be monitored for signs and symptoms of dehydration, (thirst), staff would encourage food/fluid intake as applicable, monitor bloodwork, and monitor for changes in output.…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #10) reviewed for nutrition, the facility failed to ensure the resident received the diet per physician's order. The findings include: Resident #10 was admitted to the facility with diagnoses that included partial loss of teeth, anxiety, and dysphasia. A speech therapy evaluation and plan of treatment dated 10/18/22 identified swallowing evaluation done after Resident #10 demonstrated poor use of compensatory strategies for safe swallowing with soft diet during quarterly screen. Swallow evaluation is warranted to determine safest strategies and least restrictive diet in order to minimize the risk of aspiration, train and implement compensatory strategies. Treatment for dysphasia oropharyngeal phase. Goal was to have resident and caregiver utilize safe swallowing compensatory strategies in 5 out of 5 opportunities given minimal verbal and visual cueing in order to support safe…

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, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #16) reviewed for indwelling catheters, the facility failed to implement measures, including resident education, to ensure the drainage bag was secured off the floor to maintain infection control, and for 1 resident (Resident #64) reviewed for transmission-based precautions, the facility failed to ensure staff in a covid positive room wore the appropriate PPE. The findings include: 1. Resident #16 was admitted to the facility in May 2015. Diagnoses included history of urinary tract infections and urinary retention with the use of an indwelling catheter. The annual MDS dated [DATE] identified Resident #16 had intact cognition, required total assistance with transfers and toilet use, and had an indwelling catheter. The care plan dated 9/14/22 identified Resident #16 had an indwelling catheter with interventions to monitor intake and output, provide foley care per policy, 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 observation, review of facility documentation, facility policy, and interviews the facility failed to ensure resident rooms and other living areas were well maintained. The findings include: Observations on 9/21/20 at 11:50 AM through 1:00 PM, and on 9/23/20 at 10:00 AM, and on 9/24/20 at 8:23 AM with the Director of Environmental Services identified the following: a. Damaged, chipped and/or marred bedroom walls on A wing in rooms [ROOM NUMBER], on B wing in rooms [ROOM NUMBER], on C wing in room [ROOM NUMBER], 351, and 355 and on D wing in rooms 404, and 407. b. Damaged, rusty, chipped, marred bedroom radiators on A wing in rooms [ROOM NUMBERS], on B wing in rooms [ROOM NUMBER], and on C wing in rooms 350, and 357. c. Damaged, broken and/or missing dresser drawer knobs on A wing in rooms 106, 109, 110, 112, and 113, and on B wing in rooms 221, 222, 224, and 228. d. Damaged and/or broken window blind on A wing in rooms 105, 108, 111, 112, 117, and 118, on B wing in rooms 233, and 237, and on C wing 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 review of the clinical record, facility documentation, facility policy and interview for 2 of 3 residents (Resident #46 and #73) reviewed for pressure ulcers, the facility failed to ensure nutritional assessments and skin risk assessments were completed according to standards of practice. The findings include: 1. Resident #46's diagnoses included morbid obesity, type II diabetes mellitus and anemia. The annual MDS dated [DATE] identified Resident #46 had intact cognition, required total assistance with bathing, transfers and toilet use, extensive assistance with bed mobility and supervision with eating. Additionally, the MDS identified Resident was 70 inches tall and weighed 298 lbs., was at risk for developing pressure ulcers, had a skin tear and moisture associated skin damage. Physician's order dated 8/26/20 directed to provide a carbohydrate consistent diet and diabetic evening snack, and apply triad hydrophilic wound dress paste topically to groin and buttocks every shift for wound prevention for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident's #24 and 66), reviewed for accidents, the facility failed to implement the necessary interventions to ensure residents were free from smoking materials on their person, and were supervised when smoking. The findings include: 1. Resident #24 was admitted to the facility with diagnoses that included dementia and chronic pain syndrome. The Smoking assessment dated [DATE] identified Resident #24 was forgetful and was taking psychotropic and narcotic medications. The Smoking Safety Screen dated 7/16, 7/23 and 7/30/20, identified Resident #24 agreed with the facility smoking policy and was safe to smoke with supervision. The admission MDS dated [DATE] identified Resident #24 had intact cognition and required limited assistance for bed mobility, transfers, walking in his/her room, walking in the corridor, locomotion of the unit, dressing, toileting and personal hygiene. The Smoking Agreement…

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, review of facility policy and interviews, the facility failed to maintain 2 of 4 medication carts in a clean and sanitary manner. The findings include: a. Observation of the medication cart on D wing with LPN #1 on 9/21/20 at 11:10 AM identified an accumulation of loose medication (pills) and/or blister pack back covers in the bottom of the first drawer, and/or stains and spilled liquids on the bottom of second drawer. Interview on 9/21/20 at 11:12 AM with LPN #1 indicated she was not aware of the loose pills and/or blister pack back covers and/or stains and/or spilled liquids at bottom of medication drawers. LPN #1 indicated it is the responsibility of the nurses to keep the medication cart clean. b. Observation of the medication cart on B wing with RN #1 and LPN #2 on 9/21/20 at 12:05 PM identified an accumulation of loose medication (pills) and/or blister pack back covers at the bottom of first drawer and/or stains and spilled liquids at the bottom of second drawer. Interview with LPN #2 on 9/21/20 at 12:06 PM indicated she was not aware the loose pills…

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, review of facility documentation, facility policy and interview, the facility failed to consistently maintain food temperature logs according to established criteria. The findings include: Review of the facility's food temperature logs for August and September 2020 on 9/21/20 at 10:12 AM failed to reflect consistent monitoring. Food temperatures were not documented during the dinner service on the following dates; 8/8, 8/9, 8/14, 8/15, 8/22, 8/23, 8/28, 8/29, 9/2, 9/4, 9/13 and 9/14/20. Food temperatures were not documented during the breakfast and lunch service on the following dates; 8/23, 9/5 and 9/20/20. Interview with the Food Service Director on 9/21/20 at 10:12 AM identified he would expect the kitchen staff to document all temperatures for hot and potentially hazardous foods ensure food safety and the prevention of food borne illness. Review of the policy for Food Safety identified hot foods or potentially hazardous foods would leave the kitchen or steam table at 140 degrees Fahrenheit or above. The Food Service Director would maintain records of such…

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, review of facility documentation, facility policy and interviews, the facility failed to ensure foods were prepared under sanitary conditions. The findings include: 1. Observation on 9/21/20 at 10:22 AM during the tour of the kitchen and interview with the Food Service Director identified a large fan covered in a dirt like substance had been blowing directly on clean plates and plate covers that had been removed from the dishwasher. The Food Service Director identified the fan covered in a dirt like substance should not have been blowing on the clean plates and plate covers and kitchen staff was responsible to ensure the fan was clean. Subsequent to surveyor inquiry a staff member from housekeeping cleaned the fan. 2. Intermittent observations on 9/21/20 from 9:45 AM to 10:40 AM, 55 minutes, identified a large metal pan that contained the lunch meal of pasta [NAME] with ham was left opened to air. A rubbish barrel had been placed against the countertop near where the pasta [NAME] was left…

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, review of facility policy, and interviews the facility failed to maintain the dumpster and compactor area in a sanitary manner. The findings include: Observation on 9/21/20 at 10:45 AM with the Food Service Director of the outside dumpster area identified the dumpster was uncovered with waste noted on the ground around the receptacle and trash compactor. Items included greater than 10 pairs of gloves, surgical masks, soiled cleansing wipes, old food, plastic utensils and paper cups which were scattered around the dumpster, compactor, parking lot and into the wood line behind the dumpster. Furthermore, a porcelain toilet was observed behind the dumpster. Interview with the Director of Maintenance on 9/21/20 at 10:45 AM identified maintenance staff are responsible to clean around the dumpster and compactor throughout the week and weekends. The Director of Maintenance was unable to identify why the cleaning did not occur. Review of the Rubbish Disposal policy identified food-related garbage and rubbish shall be disposed of in accordance with current state laws…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #22) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was treated in a dignified manner. The findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic viral hepatitis C, type 2 diabetes and hypertension. The admission MDS dated [DATE] identified Resident #22 required extensive assistance with personal care. The care plan dated 3/6/20 identified Resident #22 was alert and oriented, forgetful at times and had a behavior problem of being accusatory towards staff. Interventions included to provide opportunities for positive interaction and attention and to stop and talk while passing by. A Reportable Event Form dated 5/23/20 identified Resident #22 reported a nurse aide (NA #1) slammed his/her right hand in the bedroom door. Resident #22 was transferred to the hospital for further evaluation of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #22) reviewed for mistreatment, the facility failed to ensure an allegation of neglect was reported to the State Agency per established requirements. The findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic viral hepatitis C, type 2 diabetes and hypertension. The quarterly MDS dated [DATE] identified Resident #22 had intact cognition and required extensive assistance with bed mobility, transfers, dressing and hygiene, and required total assistance with toilet use. The corresponding care plan identified Resident #22 had a self-care deficit with interventions that included for staff to provide assistance with all ADL's. A Grievance Form dated 6/16/20 identified Resident #22's responsible representative called the facility and informed the ADNS that Resident #22 reported he/she had not been provided care during the weekend of 6/13/20 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, facility policy, and interviews for 1 resident (Resident #73) reviewed for wounds, the facility failed to ensure a nutritional assessment was completed when the resident was identified with impaired skin integrity. The findings include: Resident #73 was re-admitted to the facility on [DATE] with diagnoses that included diabetes and multiple sclerosis. The 5-day MDS dated [DATE] identified Resident #73 had intact cognition, required extensive assistance with bed mobility, personal care and total assist with transfers. The MDS further identified Resident #73 had no pressure ulcers and was at risk for the development of pressure ulcers. A Wound Consultation dated 6/2/20 identified a dermatologic rash noted on the coccygeal region that measured 0.6cm x 0.3cm and that the plan of care was discussed with the wound treatment nurse. A Wound Consultation dated 6/9/20 noted the dermatologic rash on the coccyx region was resolved. The care plan dated 6/11/20…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #6) reviewed for Intravenous Therapy (IVT), the facility failed to ensure a documented assessment of the insertion site every shift, and failed to ensure the physician's order included the rate of infusion for a IV medication. Additionally, the facility failed to ensure policies and procedures were updated annually, and that training and competencies were completed annually. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis of the left ankle, diabetes and peripheral vascular disease. The admission MDS dated [DATE] identified Resident #6 had intact cognition and required extensive assist with personal care. Physician's order dated 9/18/20 directed to administer IV Cefepine (antibiotic medication) 2gm/100ml via IV every 8 hours. The order lacked the infusion rate. Review of Nurse's Notes dated 9/18/20 through…

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.