Stratford Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, policy review, and clinical record review, the facility failed to have orders for verifying the amount of water to flush the feeding tube when administering medications for 1 of 1 residents reviewed (Resident #35). The facility reported a census of 36 residents. Findings include: Resident #35's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) was not able to be completed. A Staff Assessment for Mental Status indicated Resident #35 had severely impaired decision making. The MDS identified Resident #35 was dependent on staff for bed mobility and transfers Resident #35's MDS included diagnoses of traumatic brain injury, traumatic subdural hemorrhage (bleeding in the brain), altered mental status, persistent vegetative state (inability to move or talk), and dysphasia (difficulty speaking). The MDS documented Resident #35 used a feeding tube while a resident in the last 7 days. The Care Plan Focus revised 2/6/25 indicated 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 observations, record review, staff interviews, resident interview and policy review, the facility failed to change nebulizer tubing for 1 of 1 resident reviewed (Resident #33) for respiratory services. The facility reported a census of 36 residents. Findings Include: The Minimum Data Set (MDS) assessment for Resident #33 dated 4/3/25 identified a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. The MDS included diagnoses of hypertension, cerebrovascular accident (CVA), aphasia (difficulty speaking) and dysphagia (difficulty swallowing). The MDS documented Resident #33 used a feeding tube while a resident in the last 7 days. On 5/18/25 at 9:24 AM, observed Resident #33's nebulizer machine sitting on the bed side table with the tubing connected to the machine and mask/chamber sitting behind the machine on the table. The nebulizer mask/chamber was marked/dated 10/14/24. The nebulizer mask was dirty with dust particles and had dried liquid spots on it.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #35) with a feeding-tube. In addition, the facility failed to complete adequate hand hygiene and gloving for 2 of 8 residents reviewed (Residents #29 and #21) during medication administration. The facility reported a census of 36 residents. Findings include: 1. Resident #35's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) was not able to be completed. A Staff Assessment for Mental Status indicated Resident #35 had severely impaired decision making. The MDS identified Resident #35 was dependent on staff for bed mobility and transfers Resident #35's MDS included diagnoses of traumatic brain injury, traumatic subdural hemorrhage (bleeding in the brain), altered mental status, persistent vegetative state…

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, policy/procedure review, resident and staff interview the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 10 resident reviewed. (Resident #9). The facility identified a census of 37 residents. Findings include: Resident #9's Minimum Data Set (MDS) dated [DATE], indicated they could make themselves understood and could understand others. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #9 as dependent with putting on/taking off footwear and showers/baths. The MDS included diagnoses of cancer, anemia (low blood iron), hypertension (high blood pressure), anxiety, depression and reduced mobility. The Care Plan Focus initiated 2/10/23 indicated Resident #9 could independently meet their emotional, intellectual, physical and social needs. The Interventions included: a. All staff will converse with her…

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 and resident interviews, the facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for 3 out of 3 residents interviewed (Residents #2, #33 and #87). The facility reported a census of 34 residents. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2 required total assistance from staff for transfers, bed mobility, dressing and toilet use. The MDS included diagnoses of hypertension (high blood pressure), heart failure, renal insufficiency (impaired kidney function), depression and post-traumatic stress disorder (PTSD). On 7/25/24 at 8:00 AM with Resident #2 reported he waited for someone to answer the call light longer than 15 minutes frequently. Resident #2 reported he tracked the time by looking at his watch. 2. Resident #33's Minimum Data Set (MDS) assessment 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.

Based on observations, staff interviews, and facility policy review the facility failed to prepare and serve food under sanitary conditions. The facility identified a census of 34 residents. Findings include: On 7/24/24 at 11:55 AM watched Staff A, Cook, during the noon meal. Without preforming hand hygiene, Staff A applied gloves started to prepare and serve the meal. Staff A touched the plates, utensils, serving pans, and paper menus. Without changing their gloves or completing hand hygiene, Staff A reached into the bread sack to get a piece of bread, placed it on the plate, added meat with the utensil, and then used the knife to cut the sandwich. Staff A continued with the soiled gloves touching the meat and bread to pull them apart to add the mashed potatoes in between them. Staff A removed their gloves to get a cup of butter and barbeque sauce for another staff person. Staff A washed his hands and applied new gloves. Staff A continued to serve the noon meal with his gloved hands touching the utensils, serving pans, menus, plates, meat, and bread. On 7/24/24 at 1:45 PM 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 failed to complete assessments for 1 of 1 resident reviewed (Resident #26) to determine if his abilities remained unchanged or declined. Resident #26 had impairment on both sides of his upper and lower extremities. He did not have a restorative nursing program. The facility reported a census of 34. Findings include: Resident #26's Minimum Data Set (MDS) dated [DATE], indicated he had an impairment on one side of his upper and lower extremities. Resident #26's MDS dated [DATE], indicated he had an impairment on both sides of his upper and lower extremities. The Care Plan reviewed lacked a restorative nursing program. The Nursing to Therapy Communications dated 12/11/23 indicated physical and occupational therapy to evaluate and treat due to admission to the facility. The Occupational Therapy Treatment Encounter Note(s) dated a. 12/22/23 reflected Resident #26 stated he is weak and would benefit from a Restorative Nursing Program (RNP). Therapy…

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

Based on observations, interviews, and record review, the facility failed to change and label oxygen (O2) tubing for 1 of 2 residents reviewed (Resident #87). Review of Resident #87's July 2024 Medication Administration Record/Treatment Administration Record (MAR/TAR) reflected the facility failed to add weekly O2 tubing change on to Resident #87's record. The facility reported a census of 34 residents. Findings include: Resident #87's Census listed an admission date of 7/5/24, a hospitalization on 7/13/24, and then return to the facility on 7/15/24. The Clinical Physician Orders reviewed on 7/25/24 at 8:31 AM, included an order dated 7/5/24 for O2 via nasal cannula (NC) at 2 liters (L) while awake and 3 L while sleeping. The orders lacked an order to change Resident #87's 02 tubing. Resident #87's MAR/TAR printed on 7/25/24 at 11:08 AM, identified an order with a start date of 7/28/24 to change the oxygen tubing weekly and as needed (PRN) one time a day every Sunday for Infection Control Change and label Oxygen tubing. On 7/24/24 at 3:41 PM, observed Resident #87's O2 tubing not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, and resident interviews, the facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for 3 out of 3 residents interviewed (Residents #1, #3 and #7). The facility reported a census of 36 residents. Finding included: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required total assistance from staff for transfers, bed mobility, dressing, and toilet use. The MDS included diagnoses of hypertension (high blood pressure), heart failure, and renal insufficiency (poor kidney function). In an interview on 6/13/24 at 10:45 AM, Resident #1 reported he waited for someone to answer his call light for longer than 15 minutes frequently. Resident #1 reported that he tracked the time by looking at his watch. 2. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief…

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, the facility staff failed ensure residents could reach their call lights for 3 of 5 residents reviewed (Residents #3, #7 and #8). Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment indicated Resident #3 required total assistance from staff with bed mobility, toilet use and personal hygiene. The MDS listed Resident #3 as frequently incontinent of bowel and bladder. The MDS included diagnoses of heart failure, arthritis, depression, post-traumatic stress disorder and restless leg syndrome. The Care Plan dated of 2/13/24, indicated Resident #3 had a risk for falls related to deconditioning (declining), gait, and balance problems. The Intervention directed the staff to ensure he could reach his call light and encourage him to use it for assistance as needed. Provide prompt response to all requests for assistance. On 3/18/24…

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, staff, and resident interviews, the facility failed to provide two baths a week as directed for 1 out of 4 residents reviewed (Resident #2). Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #2 didn't resist care and required total assistance with showering or bathing. The MDS included diagnoses of heart failure, hypertension (high blood pressure), renal insufficiency (poor functioning kidneys), diabetes mellitus, non Alzheimer dementia, and Parkinson's. Resident #2's Clinical Census report listed an admission date of 11/8/23, an emergency room visit from 11/20/24 through 11/24/24, and a discharge date of 1/16/24. Resident #2's November 2023's Documentation Survey Report V2 lacked documentation to indicate he had a bath on 11/14/23 or 11/17/23. Resident #2's December 2023's Documentation Survey Report V2 lacked documentation to indicate he 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 observation, staff interviews, facility policy, Center for Disease Control and Prevention (CDC) guidance the facility failed perform hand hygiene after staff touched their mask prior to delivering food; failed to put a barrier under medication supplies; and failed to remove (doffing) personal protective equipment (PPE) and complete hand hygiene after exiting a COVID positive room to prevent the spread of COVID-19 for residents. The facility reported a census of 37 residents. Findings include: On 1/2/23 at 12:03 PM observed Staff D, Dietary Manager Assistant, pull her mask back up prior to delivering the meal to a resident in the dining room without doing hand hygiene. As she delivered the meal, she touched the rim of the glasses with her hands. On 1/2/23 at 12:28 PM witnessed Staff C, Dietary Cook, on her phone, then put her phone into her scrubs pocket, and adjust her mask. She did not perform hand hygiene and proceeded to grab a foam container for food, touching the inside of the container with her hand, and placing the food on the same surface she touched. She then…

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, staff interview, and facility policy review, the facility failed to promptly identify and intervene for an acute change in a resident's condition after a fall for 1 of 4 residents reviewed (Resident #2). The facility failed to recognize the change in condition with Resident #2 as he rubbed his right knee and grimaced during cares for two days before an x-ray revealed a fracture in his hip. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. He required extensive assistance of 2 persons with all activities of daily living (ADLs). The assessment reflected that he did not have limitations in his range of motion (ROM) for his upper or lower extremities. The MDS indicated that Resident #2 did not experience pain. The assessment included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia, anxiety, bipolar disorder (a mental health…

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, staff interviews and facility policy review the facility failed to implement Care Plan interventions and adequate supervision to ensure the safety of residents at the facility following a resident to resident altercation on 8/6/23 for 2 of 3 residents reviewed (Residents #2 and #3). Resident #2 went into Resident #3's room as he slept. When Resident #3 woke up and asked Resident #2 to leave his room, Resident #2 hit Resident #3 with a shoehorn. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. He required extensive assistance of 2 persons with all activities of daily living (ADLs). The assessment included diagnoses of hypertension (high blood pressure), non-Alzheimer's dementia, anxiety, bipolar disorder (a mental health disorder affecting the mood), and muscle weakness. The MDS documented the resident with physical behavioral symptoms directed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, staff, and physician interview, the facility failed to prevent medication errors for residents for 1 of 3 residents reviewed (Resident #1). The facility failed to administer an intramuscular medication as ordered, resulting in Resident #1 receiving more that his ordered medication dosage. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #1 required extensive assistance from 2 persons for transfers, dressing, toilet use, and personal hygiene. The assessment listed Resident #1 as frequently incontinent of bowel and bladder. The MDS included diagnoses of non-Alzheimer's dementia, anxiety, schizophrenia and obsessive compulsive disorder. The MDS reflected that Resident #1 received an antipsychotic medication for 7 out of 7 days in the lookback period. The Transfer Form dated 9/18/23 at 9:13 AM, listed diagnoses 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 observation, interviews and policy review, the facility failed to treat a resident with respect and dignity for 1 of 5 residents reviewed (Residents #5). Findings included: Resident #5's Minimum Data Set, dated [DATE] identified a Brief Interview for Mental Status score of 3, indicating severely impaired cognition. The MDS included diagnoses of non-Alzheimer's dementia, aphasia, profound intellectual disabilities and bipolar disorder. Residents #5 Care Plan Focus revised 4/13/23 indicated that she had times that she hit or bit herself and would yell out loudly. The Goal specified to decrease inappropriate behavior occurrences by next review. The Interventions directed the following: a. Revised: 10/12/18 - Sometimes Resident #5 has restlessness, yells out, and excessively bites her arm protectors indicating that she is too warm or there is too much stimulus around her. b. Revised: 10/12/18 - Take her for a walk in her wheelchair outside as the weather permits. On 5/23/23 at 12:35 PM witnessed Resident #5…

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 and staff interviews the facility failed to have a resident's correct advanced directives (what to do in case a resident's heart stops beating) in their electronic health record (EHR) and the facility's Code Status book for 1 of 16 residents reviewed (Resident #3). Findings include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] list an admission date of [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS included diagnoses of heart failure, renal insufficiency (poor kidney function), and diabetes mellitus. Resident #3 Clinical Physician Orders listed an order dated [DATE] of do not resuscitate (DNR). The facility's Code Status book, located at the nurses' station, included Resident #3's Cardiopulmonary Resuscitation and DNR Oder Declaration Form, signed by him on [DATE]. The form identified that Resident #3 wished to have cardiopulmonary resuscitation (CPR) to prolong his life. 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 clinical record review and staff interview, the facility failed to provide at least two days' notice to a resident or their representative before they discharged from skilled services (SNF) for 1 of 3 residents reviewed for liability and appeal notices (Resident #136). Findings include: Resident #136's Minimum Data Set (MDS) assessment dated [DATE] listed her most recent Medicare Stay as 4/30/22 until 5/10/22. The MDS identified a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. The MDS included diagnoses of cancer, Alzheimer's disease, and chronic obstructive pulmonary disease (long-term lung impairment that affects breathing). The SNF Beneficiary Protection Notification review completed by the facility for Resident #136 listed the she started skilled services on 4/30/22 and the last day of covered Part A services (skilled services) as 5/10/22. The form indicated that the facility determined Resident #136's end of her skilled services as voluntary and/or…

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

Based on clinical record reviews and staff interviews, the facility failed to complete the quarterly Minimum Data Set (MDS) assessment within the required 92 days for one of sixteen residents reviewed (Resident #30). Findings include: Resident #30's clinical record reviewed on 5/22/23 identified an admission MDS assessment completed on 1/20/23. The clinical record listed a quarterly assessment due by 4/22/23. Resident #30's clinical record lacked documentation of a completed quarterly assessment. The MDS Completion and Submission Timeframes revised July 2017 documented timeframes for completion and submission is based on the current requirements published in the Resident Assessment Instrument (RAI) Manual. The Centers for Medicare and Medicaid Services (CMS) instructed that the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA, a law passed by congress in 1987 to reform nursing homes) that directs that a resident must have a non-comprehensive assessment completed at least every 92 days following the previous OBRA assessment of any type. The facility tracks…

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 resident interviews, clinical record reviews, and staff interview, the facility failed to include a resident in the Care Plan participation/conference for one of twelve residents reviewed (Resident #12). Findings include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 2/8/23. The MDS included diagnoses of cancer and anxiety disorder. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment for decision-making. On 5/21/23 at 1:39 PM Resident #12 stated she has not attended a Care Conference since her admission. The Care Plan Conference Signature Page included Resident #12's name to indicate the staff reviewed the Baseline Care Plan and Order Listing Report on 2/10/23 with her. The form lacked additional documentation that Resident #12 attended a Care Conference. On 5/23/23 at 2:25 PM, the Director of Nursing stated she expected the staff to offer the resident inclusion in the participation of their Care Plan…

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 interviews, observations, and clinical record review, the facility failed to follow the six rights of Medication Administration (dose, time, label, person, medication, and route) for 1 out of 7 residents reviewed (Resident #7). During an observation of the medication pass, the nurse discovered an incorrect count of a resident's controlled substances. After determining, a different resident received that medication the nurse removed the medication from that resident. After removing the medication, the nurse reported that she planned to tape the medication into the resident's card of medications to make it even. Findings include: Resident #7's May 2023 Medication Administration Record (MAR) listed an order dated 12/7/20 for Lyrica (pain medication that works on the nerves) Capsule 150 milligrams (MG) (Pregabalin). The order directed to give 150 MG by mouth three times a day for pain. Resident #30's May 2023 MAR listed an order dated 3/28/23 20 for Lyrica Capsule 150 milligrams (MG) (Pregabalin). The order directed to give 150 MG by mouth three times a day for neuropathy…

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.