Crossroads of Flowery Branch of Journey LLC, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect a significant weight loss for two of 12 residents (Resident (R) 8 and R5) reviewed. The deficient practice had the potential to result in unmet care needs.Findings include: Review of the facility's policy titled, Conducting an Accurate Resident Assessment, dated 3/20/2025, revealed, . Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status . The physical, mental, and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses . dietitians, and other professionals .1. Review of R8's admission Record, located under the Profile tab of the electronic medical 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, resident and staff interviews, record review, and facility policy review, the facility failed to update care plans to reflect a significant weight loss with current intervention for two of 12 residents (Resident (R) 8 and R5) reviewed. The deficient practice had the potential to result in unmet care needs regarding nutrition. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 3/20/2025, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment .1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to identify a severe weight loss, re-assess nutritional needs, and implement interventions in a timely manner to aid in the prevention of weight loss for two of 12 residents (Resident (R) 8 and R5) reviewed. R8 had a recorded weight loss of 18.65% (percent) in less than three months. R5 had a recorded weight loss of 19.57% in five months. Findings include: Review of the undated facility policy titled, Weight Management Policy and Procedure revealed a weight report which reflected significant weight changes was generated monthly (by the 10th of the month) and reviewed by the dietary manager, Registered Dietician (RD), and Director of Nursing (DON). A significant weight change was defined as 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. Weekly weights were completed for residents exhibiting significant weight changes.1. Review of R8's admission Record, located under the Profile tab 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 staff interviews, record review, review of the facility's policy titled Nurse Aide Training Program, and review of the Alliant Certified Nursing Assistant (CNA) Annual Report, the facility failed to monitor and verify two of 29 CNAs (CNA AA and CNA FF) completed the minimum required training hours during the last review period of February 1, 2023 - January 31, 2024. The facility census was 87 residents. Findings include: Review of the policy titled Nurse Aide Training Program dated February 1, 2022, under the section titled Policy Explanation and Compliance Guideline revealed, 2. Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. (b). It is the responsibility of the employee to attend/complete mandatory in-service training to maintain employment with the facility. Review of the Alliant Certified Nursing Assistant (CNA) Annual Report, dated 7/5/2024 for review period 2/1/2023 - 1/31/2024 revealed, a staff development review was conducted on 7/5/2024. Under the section titled, Problems…

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 resident and staff interviews, review of resident council minutes, and review of the facility's policy's titled Resident Council Meeting policy, the facility failed to assure that a follow-up was completed and communicate its decisions related to resident concerns and recommendation voiced during resident council meetings. This deficient practice had the potential to have an adverse effect on any resident who voiced a concern and/or recommendation. The facility census was 87 residents. Findings Include: Review of the facility's policy titled Resident Council Meetings, dated 2/2/2022, under the section titled Policy revealed, This facility supports the rights of residents to organize and participate in residents' groups, including a Resident Council. This policy provides guidance to promoting structure, order, and productivity in these group meetings. Under the section titled Policy and Explanation and Compliance Guidelines revealed, 5. The Activity Director shall be designated if approved by the group, to serve as a liaison between the group and facilities 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 observations, resident and staff interviews, and review of the facility's policy titled, Maintenance Inspection, the facility failed to maintain the facility in a safe, clean, comfortable, homelike environment as evidenced by six of 56 resident rooms with furniture and/or packaged terminal air conditioners (PTACs) in disrepair. Specifically, rooms A6-2, B10-1, C18-2 had dressers with missing drawers and/or knobs and rooms C13, C15, C18, and C19 had PTACs that leaked water onto the floors. This deficiency had to potential to diminish the quality of life for the residents in rooms with dilapidated furniture and create a safety hazard for residents in rooms with leaking PTAC units. Findings include: Review of the facility's policy titled, Maintenance Inspection, dated 8/1/2022, under the section titled, Policy Explanation and Compliance Guidelines revealed, 1. The Director of Maintenance Services will perform routine inspections of the physical plant using a Maintenance Checklist. 3. All opportunities will be corrected immediately by maintenance personnel. 1. Observation 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.

Based on observations, staff interviews, and review of the facility's policy titled, Hand Hygiene, the facility failed to ensure hand hygiene practices were maintained to prevent the potential for infections and cross contamination. Specifically, the facility failed to perform hand hygiene after passing out each meal tray for residents on one of three halls (Hall A) that was observed during lunch. Findings Include: Review of the facility's policy titled Hand Hygiene, dated February 1, 2022, under the section titled Policy revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under the section titled Policy Explanation and Compliance Guidelines revealed, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol based hand…

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 staff interviews, record review, and review of the facility's policy titled Documentation in Medical Record, the facility failed to ensure accurate documentation was completed regarding a change of condition for one resident (R) (R1) out of six sampled residents reviewed for notification of change. Findings Include: Review of the undated facility's policy titled, Documentation in Medical Record under Policy revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Under the section titled Policy Explanation and Compliance Guidelines revealed, 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no…

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

Based on observations, interviews, and policy review, the facility failed to ensure staff entering the kitchen wore a hairnet, failed to ensure food items were labeled, dated, and discard after Best Use By date, and failed to ensure dietary staff properly used the three-compartment sink to prevent food borne illness. All 92 residents were receiving an oral diet. Findings include: 1. Review of facility policy titled Food Safety Requirements dated 2/1/22, revealed under 'Policy Explanation and Compliance Guidelines' number 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. Hairnets should be worn. Observation on 11/4/22 at 8:32 a.m. revealed Certified Nursing Assistant (CNA) KK entered the kitchen and was standing in the food preparation area without wearing a hairnet. Interview on 11/4/22 at 8:32 a.m. with CNA KK, confirmed that she was in the food preparation area and was not wearing a hair net. She stated that she needed dietary staff assistance and went into the food preparation area to find someone. The CNA 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.

Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, evidenced by overflowing garbage from the dumpster and the area around the dumpster was clean and free of debris. The facility census was 92. Findings include: Observation on 11/5/22 at 9:15 a.m. during tour of the dumpster area, revealed the dumpster was full, and the top lid was not able to be closed, exposing multiple garbage bags. Continued observation revealed the wooded area behind the dumpster had multiple trash items on the ground. Interview on 11/5/22 at 9:15 a.m. with the Certified Dietary Manager (CDM) revealed that the dumpster is scheduled for trash pick-up today. Interview on 11/5/22 at 9:18 a.m. with the Maintenance Director (MD) revealed that he will call the dumpster company to ensure they get trash picked-up today. Observation on 11/6/22 at 9:10 a.m. of the dumpster area revealed dumpster continued to be full; however top lid was closed. Further observation revealed overflow garbage was observed to be in two large gray…

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 ensure that essential equipment in the kitchen was in safe working order, evidenced by the walk-in freezer and the reach-in refrigerator observed with ice build-up on the air fans. The facility census was 92 residents. Findings include: Observation on 11/4/22 at 8:52 a.m. during initial tour of the kitchen, revealed in the walk-in freezer, a three-gallon container of strawberry ice cream and a three-gallon container of chocolate ice cream placed under the air condenser. There was ice build-up of approximately two inches thick covering the entire lid of both containers of ice cream. Continued observation revealed a prepared pie in plastic packaging sitting on the top lid of the strawberry ice cream covered with ice and not able to be dislodged from the container of ice cream. On the top lid of the chocolate ice cream container was a square foiled wrapped food item that was not able to be dislodged to view label/date. Further observation revealed a shallow steam table pan under the air condenser and under the piping to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to maintain and discontinue midline intravenous (IV) sites for two residents (R) (R#1 and R#51) reviewed of six residents with a midline IV site. Findings include: 1. Review of the clinical record for R#1 revealed an admission date of 7/6/22 with diagnoses including Alzheimer's, sepsis, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R#1 had a Brief Interview of Mental (BIMS) score of six out of 15, indicating severe cognitive impairment. Section O revealed the resident received IV medications while a resident in the facility. Review of the November 2022 Physician Orders (PO) revealed an order dated 10/21/22 for midline placement for IV hydration and to discontinue midline one time only for three days dated 10/26/22. There were no orders for the care or maintenance of the IV site. Observations on 11/4/22 at 10:59 a.m., 11/5/22 at 9:00 a.m., and 11/6/22 at 10:00 a.m. revealed R#1 had a…

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

Based on interview and policy review, the facility failed to ensure nursing staff had knowledge of proper reheat procedures for resident food items brought in from outside to prevent food borne illness. The facility census was 92. Findings include: Review of the policy titled Use and Storage of Food Brought in by Family or Visitors dated 2/1/22, revealed no procedure for reheating food items to ensure safe food consumption. Facility later provided a policy titled Food Safety Requirements which is a dietary policy. The policy does have section for reheating which states reheating food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165F. Interview on 11/6/22 at 10:28 a.m. with License Practical Nurse (LPN) Unit Manager (UM) revealed that nursing staff had not been made aware of how to properly reheat resident food items brought in by family until yesterday. The Unit Manager stated she was given a sheet with temperatures for resident food but when asked what the reheat temperature for food items brought in from outside, the UM…

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 record review, staff interviews, and review of policy titled Antibiotic Stewardship Program, the facility failed to ensure it implemented an Antibiotic Stewardship Program (ASP) to include antibiotic use protocols, and a system to monitor antibiotic use protocols for three of three months reviewed. This had the potential to affect all 92 residents in the facility. Findings include: Review of policy titled Infection Preventionist dated 2/1/22 revealed under 'Policy Explanation and Compliance Guidelines' number 4. Responsibilities of the Infection Preventionist include but are not limited to: d. Oversight of the facility's antibiotic stewardship program. Review of policy titled Antibiotic Stewardship Program dated 2/1/22 revealed policy is the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Interview on 11/6/22 at 10:40 a.m. with Infection Preventionist (IP)…

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

Based on observations, interviews, and review of facility policy, the facility failed to maintain a safe and homelike environment related to disrepair of resident rooms and bathrooms including floors, walls, doors, and heat/air units for 6 of 92 resident rooms. Findings include: Review of the policy titled Preventative Maintenance Program dated 2/1/22 which documented the Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance is required. Observation and interview on 11/4/22 at 10:01 a.m. with the resident in room C-8-2 revealed the heating and air unit in his room does not provide heat. The unit was set on heat and low fan with only cool air blowing. Observation of room A-17-2 on 11/4/22 at 10:07 a.m. revealed base board pulling away from a large portion of one wall in the bathroom, and a tile with a large, chipped piece near the bathroom door. Observation of A-18-2 on 11/4/22 at 10:23 a.m. revealed moulding up wall and near floor next to bathroom door pulling away from wall and base board near floor near second closet door…

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, staff interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a person-centered care plan for one resident (R) (R#345) for right subclavian dialysis access site. In addition, the facility failed to follow the care plan for fluid restriction for R#345. The sample size was 37 residents. Findings include: 1. Review of the policy titled Care Plans, Comprehensive Person-Centered dated 2/1/22, revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the clinical record for R#345 revealed he was admitted to the facility on [DATE] with diagnoses including renal insufficiency, renal failure, and end stage renal disease (ESRD). Brief Interview…

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

Based on observation, record review, interviews, policy review, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to ensure that Licensed Practical Nurse (LPN) NN followed the policy and procedure during medication administration. Specifically, LPN NN prepared medications for R#42, who was not in the facility, and did not destroy narcotics and medications appropriately. The sample size was 37. Findings include: 1. Review of Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician practicing medicine, a dentist practicing dentistry, a podiatrist practicing podiatry, or a registered nurse practicing nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include,…

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, interviews and review of facility policy, the facility failed to provide restorative services as recommended by occupational and physical therapy for one resident (R)(#31) and related to splint use and contracture management for one resident, R#60, of 37 samples residents. Findings include: Review of facility policy titled Restorative Nursing Program dated 2/1/22 revealed it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Number 7. Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy. 1. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R#31 with a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the policy titled, Oxygen Concentrator, the facility failed to ensure oxygen equipment was free from dust build up, failed to deliver oxygen at the flow rate ordered by physician, and failed to ensure oxygen nasal cannulas were properly stored when not in use for four residents (R) (R#14, R#25, R#10 and R#15) receiving respiratory care. The sample size was 37. Findings include: Review of policy titled Oxygen Concentrator effective date 2/1/22, revealed the purpose of the policy is to establish responsibility for the care and use of oxygen concentrators. Policy Explanation and Compliance Guidelines number 4. Use of Concentrator: A. the nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula, etc.). L. keep delivery devices covered in plastic bag when not in use. Number 5. Care of the Concentrator: A. Follow manufacturer recommendations for the frequency of cleaning filters and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to monitor the right subclavian permcath site before and after dialysis and failed to adhere to the ordered fluid restriction for one resident (R) (R#345) reviewed for dialysis services. Review of the facilities Resident Census and Conditions of Residents (CMS Form 672) dated 11/4/22 revealed one resident was receiving dialysis services. Findings include: Review of the policy titled Hemodialysis dated 2/1/22, revealed the policy is to provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Compliance Guidelines number 4. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interviews, the facility failed to ensure that psychotropic medications including antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (R#32) reviewed for unnecessary medications. Findings includes: Review of the policy titled Use of Psychotropic Medication dated 2/1/22, revealed the policy statement as residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 'Policy Explanation and Compliance Guidelines' number 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If…

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.