Bayshore Pointe Nursing And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. An observation and interview with Resident #9 on 09/11/24 at 10:10 a.m. revealed unsecured medications on Resident #9's bedside furniture including Neosporin and sore throat spray. She stated she uses it from time to time. A review of Resident #9's most recent Quarterly Minimum Data Set, dated [DATE], in Section C-Cognitive Patterns, showed a Brief Interview for Mental Status score of 15 indicating she is cognitively intact. A review of Resident #9's September 2024 physician orders revealed there was no order for throat spray or Neosporin and was silent for an order of self-administration of medication. A review of Resident #9 active care plans revealed no care plan indicating self-administration of medication was in place. An interview was conducted with Staff E, LPN on 09/11/24 at 10:20 a.m. She said if she found medications at the bedside, she would tell the resident we need an order from the doctor to have that medication. If it was a medication such as sore throat spray, or Neosporin, she would call 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 observations, interviews and record review the facility did not ensure the physician was promptly notified of a positive lab result for an infection for one resident (#101) out of eight residents sampled. Findings included: On 9/11/2024 at 11:38 a.m. an observation was made of Resident #101 sitting in her wheelchair (WC) with her catheter bag hanging underneath the WC in a privacy bag with a portion of the indwelling tubing touching the ground. An observation was made of a rusty colored, heavy sediment in the tubing. On 9/11/2024 at 5:45 p.m. an observation was made of Resident #101 in her room sitting in her WC. An observation of the urine in the indwelling tubing revealed a darker rusty color than previously observed. A review of Resident #101's admission Record showed an admission date of 8/21/2024. The resident's diagnoses included acute kidney failure unspecified, malignant neoplasm of bladder, elevated white blood cell count unspecified, urinary tract infection, retention of urine unspecified, 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 observations, interviews and record review the facility failed to ensure dental services were provided for one resident (#77) of one sampled resident. Findings included: On 09/09/24 at10:37 a.m. an observation and interview was conducted with Resident #77. Resident #77 was observed with missing teeth. She said, I am missing teeth, I do not eat very well. The bread is hard. On 09/10/24 at 9:09 a.m. an observation and interview was conducted with Resident #77. She stated she was served a sausage patty and it was dry and not chewable. On 09/10/24 at 4:00 p.m. an interview was conducted with Resident #77. She stated she asked to see a dentist. She said, Some doctor came to see me a long time ago. He said somebody will be back on a Monday. I don't know when this was. They never came back. Resident #77 stated she would like to see a dentist. Review of the admission Record showed Resident #77 was admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of endometrium. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure appropriate placement was arranged prior to discharge for one resident (#5) out of two residents sampled for discharge. Findings included: A review of a Nursing Home Transfer Discharge Notice showed a 30-day notice was issued on 08/10/23 to Resident #5/Resident Representative. A certified mail receipt showed the notice was received by Resident #5's Representative on 8/11/23. The notice indicated the reason for discharge was, Your needs could not be met in this facility. A brief explanation documented on the form showed the explanation to support this action was, Behavioral and aggression towards staff and other residents. A review of an admission Record showed Resident #5 was admitted to the facility on [DATE] and was discharged on 09/01/2023. The record showed diagnoses to include, unspecified dementia with agitation, anxiety disorder, mood disorder, and delirium due to known physiological condition. A review of a Physician Order Summary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure medications were administered as ordered for one resident (#3) out of two residents reviewed for medication administration. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, and obesity. A review of a Physician Order Summary report, date range 07/26/23 - 07/31/23, revealed the following orders: Levothyroxine Sodium oral tablet 75 MCG (Micrograms) Give 1 tablet by mouth in the morning for low thyroid with start date: 7/27/23. Enoxaparin Sodium injection (Lovenox) solution prefilled syringe 100 mg/ml (Milligram/Milliliter). Inject 1 application subcutaneously two times a day for DVT (Deep Vein Thrombosis) for 14 days with a start date: 7/28/23. A review of the Medication Administration Record (MAR) for Resident #3 showed the resident did not receive her injection 1 out 8 ordered administration times. Medication administration…

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, resident and staff interview, facility menu review and meal substitution log review, the facility failed to follow the planned menus. This has the potential to affect 80 of 85 residents who consume food in the facility, including one resident (#46) and occurred for 3 of 3 meals observed during the survey. Findings included: During the lunch meal observation on the first day of the survey, 06/20/22 at 12:29 p.m., the lunch menu posted on the wall across from the main dining room showed the following foods that were planned to be served: Smothered pork chop Herbed rice (initially was planned as macaroni and cheese, but was changed) Southern style collard greens Bread or roll Frosted cake. The facility week at a glanced menu signed by a dietitian reflected the same - smothered pork chop, herbed rice, southern style collard greens, bread or roll and butter or margarine. During the lunch service (6/20/22), plain, unseasoned white rice instead of herbed rice was served and the frosted cake was not served, but rather a yellow cake with strawberry sauce poured on 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 meal observations, test tray observations, resident interviews and record reviews, the facility failed to provide resident meals that were palatable, attractive, and/or at an appetizing temperature for eight residents (#39, #46, #65, #77, #86, #137, #6 and #240) out of eight residents observed at the meal or interviewed about the facility food. Findings included: Seven residents expressed during interviews during the survey concerns with food that included food not served at an appetizing temperature and food that was unpalatable. An interview with Resident #39 on 06/20/22 at 10:54 a.m., revealed, Food is just not good, I have been here since 12/2021. I came here cause the therapy is great. Resident #46 on 06/22/2022 at 9:35 a.m. reported the food is usually cold, especially at night with lunch usually warm. When asked about the always available menu she reported she doesn't bother with it. The daily newsletter which listed the day's menus was reviewed with the resident. The lunch was to be spaghetti with meat sauce. The resident reported there was so little sauce on the…

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

Based on observation, resident and staff interview, and menu review, the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences and/or appealing options of foods with similar nutritive value to residents who had requested a different meal choice. This affected four residents (#37, #77, #86, and #137) out of 38 sampled residents. Findings included: Four residents expressed concerns during interviews throughout the survey about the inability to get alternate meal choices or have their preferences honored once they have been made known. On 06/20/22 at 11:07 a.m. Resident #37 stated he has tried to reach dietary (by phone) to make changes and he is unable to reach anyone. He stated his roommate has also tried because he needs his menu changed. He stated they have both tried multiple times over more than a week to call the number and no one answers. On 06/21/22 at 10:46 a.m. Resident #77 stated the food is always cold and they waste a lot of food. She reported they asked her what she wanted for breakfast and she has 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.

Based on observation, staff interview, and review of cleaning schedules and policies, the facility failed to ensure two Time-Temperature Control for Safety (TCS) foods were not stored too long and that preparation and serving equipment was maintained in clean condition. Findings included: During the Initial Kitchen Tour on 06/20/22 at 9:37 a.m., there was an opened gallon container of garlic cloves stored in the walk-in refrigerator that was date-marked 06/3/22. The container was less than half full. This food was stored past 7 days. This was observed by two surveyors. At 9:49 a.m., in the reach-in refrigerator #1, there was prepared vanilla pudding stored in a clear container with a green lid that was date-marked 06/4/22. This food was stored past 7 days. (Photographic Evidence Obtained) This was observed by two surveyors and the Nursing Home Administrator. During a follow up kitchen visit on 06/22/22 at 2:26 p.m., the shelf over the steam table had an accumulation of food splatter on the underside, which was directly over the steam table pans. (Photographic Evidence Obtained)…

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 interviews, the facility failed to treat each resident with respect and dignity, as evidenced by disorganization of their meal service so that residents sitting together at the same table did not receive their meals at the same time, and residents needing assistance were not provided with assistance. This affected three randomly observed residents and Resident #54 in two different dining rooms (main and 3rd floor restorative) of three dining rooms at lunch on 06/20/22. Findings included: During the lunch meal service in the main dining room on the first day of the survey, 06/20/22 at 12:40 p.m., one female resident received her pureed meal but her tablemate did not receive his meal. He was sitting there watching his tablemate eat her meal. The female resident's meal came from the restorative dining tray cart. Her tablemate finally got his tray at 1:00 p.m. The female resident was almost finished her meal. The lunch meal tray service times were as follows: 2nd & 3rd restorative dining room served at 11:45 a.m., 2nd Floor Dining room served at 12:00 p.m., 2nd…

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 medical record reviews, review of the Advanced Directive audit and review of the facility policy on Advanced Directives, and interviews with facility staff, the facility failed to ensure there was a physician's order for the code status of Do Not Resuscitate (DNR) and failed to ensure the DNR code status was reflected in the electronic medical record for two residents (#42 and #49) out of 27 residents reviewed in the initial pool. Findings included: 1. A review of the admission Record revealed Resident #42 was readmitted into the facility on [DATE] with the primary diagnosis of metabolic encephalopathy. Section C-Cognitive Patterns of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #42 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating cognitively intact. A review of the resident's Order Summary Report for June 2022 did not reflect an order for code status. A review of the Order Summary Report for discontinued orders for 05/01/22 to 06/30/22 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (#22) out of 27 residents reviewed in the initial pool, received the necessary incontinence care to maintain personal hygiene. Findings included: On 06/20/22 at 1:38 p.m., Resident #22 was observed in his room with a family member. Resident #22 was sitting in a reclining wheelchair. The family member was upset because the resident was wet and the floor was wet underneath the resident's wheelchair. The family member stated the resident was really wet today and she told the staff several hours ago that he was wet. The aide came and changed his roommate and then left. He was currently so wet, the floor beneath him was wet with urine. She just told another staff person that he needed to be changed and they got the Certified Nurse Aide (CNA) to change him. The family member said this doesn't happen very often. The family member seemed upset about the situation. A review of the admission Record showed the resident 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 observations, interviews, and record reviews, the facility failed to ensure there were no significant medication errors related to administration of insulin via an insulin pen for one resident (#32) out of one resident observed and out of eleven residents in the facility using insulin pens. Findings included: An observation was conducted on 6/21/22 at 10:40 a.m. of Staff A, Licensed Practical Nurse (LPN) performing a blood glucose check and administering Insulin Aspart Solution to Resident #32. Staff A performed the glucose check indicating the resident had a blood glucose level of 201 and needed 4 units of insulin per her sliding scale orders. Staff A, LPN retrieved a new insulin pen from the medication storage room. The LPN opened, labeled, and dated the new insulin pen. She proceeded to put on the needle, turn the dial to 4 units of insulin, then administered the medication to the resident. The LPN did not prime the insulin pen before administration. A review of the admission Record indicated…

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

Based on observation, interview and record review the facility failed to follow infection control practices related to include hand hygiene and the cleaning and disinfection of a glucometer for one (Resident #68) of three sampled residents. Findings included: An observation was made on 06/20/22 at 11:35 a.m. of Staff C, Licensed Practical Nurse (LPN) performing a blood glucose check on Resident #68. Staff C, LPN was sitting at the nursing station and walked to the medication cart and was observed to don gloves without performing hand hygiene. She was observed to open the medication cart and remove a glucometer and lay it on top of the medication cart. She removed glucometer strips from the top drawer and inserted one into the glucometer. She removed a lancet and alcohol wipes from the medication cart. Then, the nurse and surveyor went into Resident 68's room and the nurse was observed to place the glucometer and lancet on a washcloth on the resident's bed. With her same gloved hands the nurse used an alcohol wipe to clean the middle finger of the resident's left hand. The nurse used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) ensure behavioral monitoring for psychotropic medications was consistently documented for two residents (#25 and #240) of five residents reviewed, 2) obtain and consistently complete consents for use of psychotropic medications for four residents (#25, #240, #71 and #39) of five residents reviewed, and 3) perform blood glucose monitoring for one resident (#25) receiving insulin of five residents reviewed. Findings included: A record review for Resident #25 revealed an admission date of 11/09/2020, with diagnosis that included Major Depressive Disorder (MDD) and Diabetes as per the admission face sheet. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed under Section C, Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact, Section N, Insulin, antidepressant, anticoagulant and diuretic received on 7 out of 7 days. A review of the Medication Administration Record (MAR) included the following…

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 reviews and interviews, the facility failed to ensure there was a physician order for the code status of Do Not Resuscitate (DNR), and that the DNR code status was accurate on the electronic medical record, or that a care plan was in place for the Advance Directives for one resident (Resident #63) out of the sampled thirty-two residents. Findings included: A review of the admission Record revealed that Resident #63 was initially admitted into the facility on [DATE]. Section C-Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. A review of the resident's current physician orders for February 2021 revealed an order for full code dated 01/21/21. A review of the banner on the electronic medical record indicated that Resident #63's code status was full code. A review of the documents listed under the miscellaneous tab on the electronic record revealed a State 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 observations, record reviews, and interviews, the facility failed to implement the care plan related to a wander/elopement alarm for one resident (Resident #71) out of the total sample of thirty-two residents. Findings included: On 02/25/21 at 11:19 a.m., Resident #71 was observed in bed sleeping and a wander/elopement alarm was observed on his right ankle. A review of the admission Record revealed that Resident #71's most recent admission date was 01/25/21. The resident's diagnoses included, but were not limited to, dementia with Lewy Bodies, major depressive disorder, and mood disorder. A review of Section C- Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #71 had a Brief Interview for Mental Status (BIMS) score of 07 out of 15, indicating severe impairment. A review of the active physician orders as of 02/26/21 for Resident #71 revealed an order to apply a wander/elopement alarm to the right ankle due to poor safety awareness dated 02/12/21. There was no physician…

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 reviews and interviews, the facility failed to ensure treatment and care in accordance with professional standards of practice for one resident (Resident #71), by failing to notify the physician of elevated glucose levels as ordered by the physician, out of the total sample of thirty-two residents. Findings included: A review of the admission Record revealed that Resident #71's most recent admission date was 01/25/21. The resident's diagnoses included, but were not limited, to Type II diabetes, dementia with Lewy Bodies, major depressive disorder, and mood disorder. A review of Section C- Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #71 had a Brief Interview for Mental Status (BIMS) score of 07 out of 15, indicating severe impairment. A review of the active physician orders as of 01/25/21 revealed the following order: blood glucose checks before meals and at bedtime for diabetes mellitus fingerstick. Call medical doctor if blood sugar <60 or >250. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide ordered medications in a timely manner to one resident (#240) of 32 sampled residents. Findings included: A review of Resident #240's medical record revealed that Resident #240 was admitted to the facility on [DATE] with diagnoses of osteoarthritis, Alzheimer's Disease, and nondisplaced fracture of fourth cervical vertebra. A review of Resident #240's care plan revealed a problem, dated 02/10/2021, that Resident #240 was at risk for pain. Interventions included administer analgesics as ordered. A review of Resident #240's physician's orders revealed an order, dated 02/10/2021, for Tramadol 50 milligrams (mg) by mouth in the morning for severe pain control, which was discontinued on 02/13/2021. Resident #240's physician's orders also revealed an order, dated 02/14/2021 for Tramadol 25 mg by mouth in the morning for pain. A review of Resident #240's Medication Administration Record (MAR) for February 2021 revealed that Tramadol 50 mg was…

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

Based on observation, interview and policy review, the facility failed to ensure expired medications were removed from one medication cart (3rd floor back hall) out of three medication carts observed, and one medication storage room (3rd floor unit) out of one medication storage room observed. Findings included: On 02/25/2021 at 2:17 p.m. an observation of the 3rd floor back hall medication cart was performed and Staff C, Licensed Practical Nurse (LPN) was present. One card of Baclofen 5 milligram (mg) tablets with an expiration date of 11/25/2020 for Resident #33 was discovered. A subsequent interview with Staff C, LPN confirmed the medication was expired, and she further stated the medication was discontinued. On 02/25/2021 at 2:25 p.m. an observation of the 3rd floor medication storage room was performed and Staff C, LPN was present. Two bottles of Aspirin 81 mg tablets were discovered with an expiration date listed as 01/21. Additionally, during an observation of the medication room refrigerator, one box of Bisacodyl 10 mg Suppositories was discovered with an expiration date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement the antibiotic stewardship program by not ensuring antibiotics were given appropriately to one resident (#244) of a total of 32 sampled residents. Findings included: A review of Resident #244's medical record revealed that Resident #244 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic atrial fibrillation, malignant neoplasm of prostate and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident #244's February 2021 physician orders revealed the following orders: - 02/20/2021 Urinalysis (UA) with reflex to culture, discontinue this order when completed and sent; discontinued on 02/20/2021. - 02/25/2021 Urinalysis (UA) with reflux to culture, discontinue this order when completed and sent. - 02/20/2021 Ciprofloxacin 250 milligrams (mg) by mouth every 12 hours for infection for 7 days. A review of Resident #244's progress notes revealed a Health Status Note, dated 02/26/2021…

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.