South Shore Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure ADL's (Activities of Daily Living) were completed for two residents (R202, R204) to allow the residents to maintain their dignity. This failure affected 2 residents out of a sample of 77.Findings include: Findings include: R202 has a diagnosis of but not limited to Syncope and Collapse, Muscle Weakness, Lack of Coordination, Need for Assistance with Personal Care, Weakness and Hypertension. R202's Brief Interview of Mental Status score is 6 which indicates severe cognitive impairment. R202 Minimum Data Set section GG-Functional Abilities documents, in part, 02 (Substantial/maximal assistance) and Personal hygiene: the ability to maintain personal hygiene, including shaving. R202's Care plan focus for ADL's dated 08/06/2025 documents, in part, R202 has an ADL Self Care Performance Deficit related to muscle weakness and Personal Hygiene: R202 requires total staff assist with shaving facial hair. On 8/04/2025 at 11:28am, surveyor…

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 redistribute pressure by maintaining the air mattress pump at the correct weight setting to prevent pressure wounds. This failure has the potential to effect one resident (R7) in a sample of 77.Findings Include: R7 was observed lying in bed on a low air mattress with an air mattress pump at the foot of the bed set on Firm which is one setting past 360lbs (pounds). On 8/4/2025 at 11:24 am, V17, RN (Registered Nurse/Agency) verified R7's air mattress pump was set past 360lbs (pounds) on firm. V17 stated she (V17) was not aware of the facilities protocol for the air mattress setting. V17 verified R7's current weight was 150.8lbs. On 8/4/2025 at 11:47 am, V8, WCT (Wound Care Technician) stated only a nurse, wound care coordinator, or the wound care tech can change the setting on a resident's air mattress pump. V8 stated an incorrect air mattress pump setting can cause a pressure ulcer wound to develop. On 8/6/2025 at 12:34 pm, V24 WCC (Wound Care Coordinator) stated R7's family requested R7 remain on a low air…

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 record review, the facility failed to update resident care plans to accurately identify isolation needs. These failures have the potential to affect 4 residents (R1, R2, R4, and R5) reviewed for isolation. Findings include: Record review of R1's physician orders document an active order for contact isolation precautions. Record review of R1's care plan does not document care planning for R1's isolation needs. Record review of R2's physician orders document an order for contact and droplet isolation precautions. Record review of R2's care plan does not document that the isolation needs were care planned during R2's stay in the facility. Record review of R4's physician orders document an active order for contact isolation precautions. Record review of R4's care plan does not document care planning for R4's isolation needs. Record review of R5's physician orders document an active order for contact isolation precautions. Record review of R5's care plan does not document care planning for R5's isolation needs. On 5/2/2025 at 12:14 PM, V2 (Director of Nursing)…

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 personal protective equipment (PPE) was readily available for use for residents that require enhanced barrier precautions and transmission-based precautions; failed to ensure linen cart was covered. These failures have the potential to affect 6 residents (R1, R4, R5, R6, R8, R9) reviewed for infection control. Findings include: 1) On 5/2/2025 at 10:30 AM, enhanced barrier precaution signs (noting that providers and staff must wear gown/gloves when providing high-contact resident care activities) were noted on the doors to resident's rooms. No personal protect equipment (PPE) was noted to be readily accessible outside the rooms. V6 (Certified Nursing Assistant) affirmed that there was no PPE available for use. V6 stated that V6 would be unable to provide care to those residents due to the lack of required PPE. On 5/2/2025 at 10:32 AM, V2 (Director of Nursing) affirmed that there was no PPE available for the staff to use for residents…

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 implement pressure ulcer prevention interventions as stated in the care plan for residents at risk for pressure ulcers. This failure has the potential to affect six residents (R2, R3, R4, R5, R6, and R7), reviewed for wheelchair cushions as a pressure ulcer prevention intervention for residents. Findings include: On 1/15/25 at 11:50am during observation of residents in the fourth-floor dining room, R2 and R3 were observed sitting in the wheelchair without pressure relieving cushion. At 12:13pm, both residents were still in the wheelchairs without cushions. At this time, V9 (CNA/Certified Nurse Assistant) who was with the residents at the time was notified and stated that she (V9) would ask Restorative. V9 stated that residents need the cushions in the wheelchair to prevent wounds. V3 (Unit Manager) also stated that she (V3) would find cushions for the wheelchairs immediately she finishes assisting the resident with lunch. On 1/15/25 at…

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

Based on interview and record review, the facility failed to have a policy and procedure in place on how to provide beneficiary notifications such as NOMNC (Notice of Medicare Non-Coverage) and ABN (Advanced Beneficiary Notice) to its residents. This failure could potentially affect 182 Medicaid / Medicare eligible residents residing in the facility with 2 residents under private pay for a total census of 184 as of 7/23/24. The findings include: On 7/23/24 at 1:10 PM facility provided a list of residents who were discharged from Medicare covered Part A stay in the past 6 months. On 07/24/24 10:40 AM V3 (SSD/ Social Service Director) said she started working in the facility January 2023 and transitioned as SSD in May 2024. V3 said NOMNC was not given for Medicare residents, it is only given for managed care / insurance residents. V3 stated she is not aware about ABN. At 11:06 AM V58 (Social Service Consultant) stated ABN should be provided to residents staying in the building and not covered by Medicare. V58 said NOMNC should be given to Medicare eligible residents within 48-72 hours…

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 reviews, the facility failed to ensure a.) kitchen staff wearing facial hair covering b.) food items were properly labeled, dated, and stored, c.) refrigerator kept clean. These failures have the potential to affect all 180 residents receiving food prepared in the facility's kitchen. Findings include: On 07/23/24 at 9:10 AM, during initial tour with V5 (Dietary Manager) observed V6 (Dietary Aide) walking around the kitchen. V6 had a mustache and beard which was not covered with a beard protector/covering. V6 stated, I got going and forgot to put on a beard protector this morning. I should be wearing one now. I'll go put one on. V5 stated there is an adequate supply of beard guards in stock and V6 should be wearing a beard guard in the kitchen. On 07/24/24 at 9:08 AM, V5 stated beard guard's purpose is to prevent hair from falling in food and to prevent contamination of the food. V5 stated any kitchen employee with a beard or facial hair should put on a beard guard before they enter the kitchen. On 07/23/24 at 9:18 AM, V5 stated all items…

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 update infection prevention and control policies at least annually resulting in current policies and procedures dating as far back as 2006. This failure has the potential to affect all residents at the facility. The facility also failed to ensure shared equipment was sanitized between each use for 3 [R62, R106, R129] of 4 [R127] residents reviewed for medication administration observation. Findings On 07/23/24 at 02:14 PM infection prevention and control policies were reviewed. Policy titled Infection Control Protocol for All Nursing Procedures was revised January 2019. Policy titled Blood and Body Fluids Exposure was revised August 2008. Policy titled Cleaning Spills or Splashes of Blood or Body Fluids was revised December 2006. Policy titled Exposure Classification or Tasks and Procedures was revised December 2006. Policy titled Exposure Determination was revised December 2006. Policy titled Handwashing/Hand Hygiene Policy had an effective date of March 2020. Policy titled Hepatitis B Vaccination was revised…

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 maintain effective pest control as evidenced by flying insects visualized both in resident rooms and common areas in the facility. This failure had the possibility of affecting the one hundred and eighty-four residents at the facility. Findings: On 07/23/24 at 9:29 AM V24 (Licensed Practical Nurse) stated that she tries to have the Certified Nurses Aides (CNA) get food trays picked up quickly after meals so that there are no fruit flies. V24 stated that she saw fruit flies on one occasion a few years ago in the unit kitchenette area. On 07/23/24 at 9:34 AM V32 (Certified Nurses Aide) stated, In the summer, we have seen a fly here and there if there are windows open. On 07/23/24 at 9:40 AM - V39 (Housekeeping) stated, We have little gnats. I let V40 (Maintenance Director) know when I see one so that V40 can call pest control. As surveyor was speaking to V39, a flying insect flew by the surveyor's face. V39 stated, I just saw one. It just flew by your head. It looked like a little gnat. It is only common in 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, interview and record review the facility failed to provide physician generated diet orders. These failures affected 5 residents (R7, R15, R75, R110, R152) of 7 residents reviewed for nutrition in a total sample of 36. Findings include: On 07/23/24 at 12:29 PM, observed R110 eating lunch in unit dining room. R110's meal ticket read double portions. R110 received one scoop of mashed potatoes, a single portion of yellow squash, and a single portion of Turkey Pot Roast. R110 stated, Sometimes I get doubled portions and sometimes I don't. The doctor requested it because he wants me to get double portions. On 07/23/24 at 12:33 PM, observed R75 sitting in the unit dining room. R75 received a single portion of Turkey Pot Roast, single portion of Yellow Squash, and one scoop of mashed potatoes. R75's meal ticket read double portions as part of diet listed. R75 stated, I'm supposed to get double portions, but I didn't get it. On 07/23/24 at 12:57 PM, observed R15 sitting on bed in R15's room with lunch meal on R15's bed table. R15 took the dome lid off the plate.…

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: (a) follow standards of professional practice and facility policy by leaving medications at the bedside of one resident (R488); (b) ensure that one medication cart were locked during medication administration; (c) properly date opened multi-dose eye drops, insulin vials and pen; (d) properly discard expired house stock medication from 4 of 8 medication carts and 2 of 4 medication storage room inspected for medication storage and labeling. The findings include: On 7/23/24 at 11:01 AM Inspected 2 east medication cart with V9 (Licensed Practical Nurse / LPN) and observed R94's opened Insulin Lispro vial with no open date. Pharmacy label indicated discard after 28 days. R94's POS (Physician Order Sheet) dated 7/23/24 documented active order not limited to: Humalog injection solution 100unit/ml (Insulin Lispro inject as per sliding scale. At 11:18am 2 west medication cart inspected with V8 (LPN) and observed R13's opened Insulin Glargine pen and Aspart insulin vial with no open date. Pharmacy label 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 provide privacy and confidentiality for 3 [R62, R106, R129] of 4 residents personal medication administration record. Findings Include: On 7/23/24 at 9:25AM, Surveyor observed V11 [Licensed Practical Nurse] during medication administration. On 7/23/24 at 9:26 AM, V11 walked away from the medication cart and left the computer screen unlocked and displaying R129's personal medication information facing toward the hallway, visible to anyone walking pass. On 7/23/24 at 9:33 AM, V11 walked away from the medication cart and left the computer screen unlocked and displaying R106's personal medication information facing toward the hallway. On 7/23/24 at 9:46 AM, V11 walked away from the medication cart and left the computer screen unlocked and displaying R62's personal medication information facing toward the hallway. On 7/23/24 at 10:02 AM V11 stated, I forgot to lock the computer screen before walking away. I need to lock the computer screen to protect the resident's personal information from other residents or…

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

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' call lights were within reach for two (R43, R171) out of a total sample of 36 residents reviewed for accommodation of needs. Findings Include: 1. On 07/23/24 at 11:30 AM, surveyor observed R171 lying in bed. Surveyor observed R171's call light on the floor. R171 stated R171 cannot get out of bed without help, and R171 cannot find or reach for R171's call light. R171 must scream for help sometimes when the call light is on the floor. R171 stated the staff do not like when R171 screamed for help. R171 told staff to always keep R171's call light within R171's reach. On 07/23/24 at 11:46 AM, V23 (Certified Nursing Assistant/CNA) and surveyor observed R171's call light on the floor. V23 stated call light should not be on the floor, R171's call light should be within R171's reach. V23 stated the potential problem is that R171's need will not be met. V23 then attached the call light to R171's reach. On 07/23/24 at 2:30 PM, V2 (Director of Nursing/DON) stated, it is the expectation of V2…

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 record review the facility failed to obtain physician order for code status of 1 (R109) resident reviewed for advance directives in a sample of 36. The finding include: R109 face sheet documented admission date on 3/25/2024 with diagnoses not limited to Spinal stenosis, Presence of other vascular implants and grafts, Muscle weakness (generalized), Hyperlipidemia, Chronic obstructive pulmonary disease, Bipolar disorder, Solitary pulmonary nodule, Benign prostatic hyperplasia with lower urinary tract symptoms, Vitamin d deficiency, Paraplegia, Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, Obstructive sleep apnea, Other seizures. On 7/24/24 at 10:40 AM V3 (Social Service Director / SSD) said they are assisting resident and family with advance directives including code status. V3 said code status needs to have an order from the physician. Nurses are supposed to obtain an order for code status whether full code or DNR (Do Not Resuscitate) from physician so staff would know the code status of the resident. Surveyor reviewed…

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 record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 1 (R124) of 4 residents reviewed for resident assessment in a sample of 36. The findings include: R124's face sheet documented admission date on 10/30/23 with diagnoses not limited to Type 2 diabetes mellitus, Major depressive disorder, Anemia, Schizophrenia, Bipolar disorder, Dysphagia. On 7/24/24 at 11:26 AM V42 (MDS Director) said V42 has been working in the facility for 5 years. V43 (Reimbursement specialist) said MDS assessment is done for all residents in the facility and completed by IDT (interdisciplinary team) such as SS, wound care, Activities, Dietary, Restorative, Therapy, Nursing. MDS assessment has different sections including demographics, cognition, hearing, speech, vision, mood, behavior, activities, functional abilities and goals, incontinence, diagnosis, health conditions, nutrition, dental, skin, medications, special treatment and procedures,…

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 record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 3 (R99, R147, R167) of 4 residents reviewed for resident assessment in a sample of 36. The findings include: R99's face sheet documented admission date on 4/13/22 with diagnoses not limited to Type 2 diabetes mellitus, Neuropathy, Atrial Fibrillation, Heart failure, Obstructive sleep apnea, Anemia, Acquired absence of right and left leg below knee, Essential hypertension. R147's face sheet documented admission date on 10/20/22 with diagnoses not limited to Dementia, Major depressive disorder, Essential hypertension, other seizures, Atrial fibrillation, Hyperlipidemia, Hemiplegia and hemiparesis following Cerebral infarction, Dysphagia, Presence of pacemaker. R167's face sheet documented admission date on 2/7/24 with diagnoses not limited to Type 2 diabetes mellitus, Asthma, Hyperlipidemia, Hypothyroidism, Essential hypertension, Congestive heart…

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 and record reviews, the facility failed to conduct a Preadmission Screening and Resident Review (PASRR) for one (R101) resident out of a total sample of 36 residents reviewed for PASRRs. Findings include: Reviewed R101's 8/10/2023 admission Minimum Data Set (MDS) assessment. It documents in part an admission date of 7/28/2023. Under section A1500 PASRR, facility marked 0 to indicate that resident was not considered to have serious mental illness. R101's admission Record, however, documents in part a medical diagnosis of bipolar disorder (onset date 7/28/2023). Surveyor requested to review R101's PASRR from V1 (Administrator), V2 (Director of Nursing), and V41 (Admissions Director) on multiple occasions including on 7/23/2024 at 3:10 PM and on 7/24/2024 at 9:25 AM, 10:55 AM, 1:43 PM, and 1:58 PM. Facility provided an old pre-admission screening for R101 from 1/10/2021 directed to another facility. Facility did not provide PASRR related to R101's 7/28/2023 admission to current facility. On 7/24/2024 at 1:58 PM, V41 stated facility admitted R101 prior to V41's start…

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 ensure incontinence care was provided in a timely manner for 1 (R109) resident who needed assistance with toileting. This failure affected 1 (R109) resident reviewed for ADL (Activities of Daily Living) care in a sample of 36. The findings include: R109 face sheet documented admission date on 3/25/2024 with diagnoses not limited to Spinal stenosis, Presence of other vascular implants and grafts, Muscle weakness (generalized), Hyperlipidemia, Chronic obstructive pulmonary disease, Bipolar disorder, Solitary pulmonary nodule, Benign prostatic hyperplasia with lower urinary tract symptoms, Vitamin d deficiency, Paraplegia, Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, Obstructive sleep apnea, Other seizures. On 7/23/24 at 10:36 AM R109 observed lying in bed, alert and oriented x 3, verbally responsive. R109 stated he is not satisfied with care; he has been wet with urine and feces and was last changed around 3am and he told staff after breakfast around 8am that he needed…

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 ensure oxygen was administered as ordered, failed to ensure oxygen masks and nebulizer masks and tubing were stored following professional standards of care and facility policy, and failed to ensure residents were provided humidity while on oxygen. These failures could potentially affect three (R18, R63, R80) residents out of a total of thirty-six residents reviewed for respiratory care. Findings On 07/23/24 at 10:25 AM R63 was observed lying in bed with oxygen running at four liters per minute per nasal cannula. An oxygen mask was observed on the bedside table not in a bag. On 7/23/2024 at 10:27 AM V32 (Certified Nurses Aide) stated, We store unused oxygen masks and cannulas wrapped in a plastic bag. V32 observed the oxygen mask on R63's bedside table and stated, It should be in a plastic bag. On 7/24/2024 at 8:44 AM R63's nasal cannula was observed on the floor with the oxygen machine running at four liters per minute. V33 (Licensed Practical Nurse) stated, I will get her a new nasal cannula. I should…

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, facility failed to follow provider orders and provide speech evaluation for one resident (R176) out of a sample of seven residents (R31, R63, R106, R131, R133, R176, R488). Findings On 07/23/24 at 10:35 AM R176 stated I was expecting to get speech therapy on a regular basis, but I don't know if I should be expecting that. R176 stated that R176 has had multiple strokes. R176 stated I don't recall getting speech therapy. I have been to physical therapy. On 07/23/24 at 12:41 PM review of the orders for R176 includes Speech Therapy to Evaluate and Treat. Order was written on 5/22/2024. Order for Speech Therapy was signed by V53 (Physician) on 6/19/2024. On 7/23/2024 at 3:20 PM V52 (Director of Rehabilitation Services) stated that physical therapy (PT) services ended for R176 on 6/17/2024, occupational therapy (OT) services for R176 ended on 6/13/2024, and R176 did not have speech therapy. V52 stated that R176 was admitted to the facility for skilled therapy. V52 stated that upon new resident admission, a speech therapy evaluation 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 observation, interview, and record review the facility failed to follow facility policy and standards of professional practice in the timely education and/or administration of pneumococcal vaccine for two residents (R176, R488) out of seven residents in the sample (R31, R63, R106, R131, R133, R176, R488). Findings On 07/23/24 11:20 AM V4 (Infection Prevention Nurse) stated that resident education, resident consent, resident declination, and resident vaccination of the pneumococcal and/or influenza vaccines will be documented under immunizations in the electronic health record. On 7/23/2024 at 12 PM, the electronic health record of R31, R63, R106, R131, R133, R176, R488 were reviewed. Under the immunization record in the electronic health record, there was observed to be no education, consent, or declination of the pneumococcal vaccine for R488. There was a signed consent for R176 but no pneumococcal vaccination administration. On 07/23/24 at 3:20 PM V4 (Infection Prevention Nurse) stated that upon admission of a new resident, the staff and V4 assess what vaccines 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, interview, and record review the facility failed to provide a safe and functional environment by not ensuring the shower room floor tiles had non-skid tape attached to prevent accidental hazards. This failure has the potential to affect 142 residents residing on the 1st, 2nd, and 3rd, floor out of 193 residents. Findings include: On 05/30/24 at 11:52am, on the 3rd floor shower room in two shower stalls the six floor tiles were missing non-skid grip tapes and some were rolled up. V4 (Maintenance Director) who was present during this environment observation, stated there should be a non-skid tape on each of the tiles on the floor. At 12:02pm, 2nd floor shower room was observed with water puddle noted on the floor under the wash sink. The floors had two of the shower stalls with missing non-skid tapes. On 06/03/24 at 10:20am, the 1st floor shower stall was observed wet with peeling non-skid tape and some peeling off. V10 CNA (Certified Nurse's Aide) stated that all the residents' showers are done in the shower room. At 10:28am, V5 (Housekeeping) was made aware 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.

Based on observation, interview, and record review the facility failed to ensure that urine collection bag was placed appropriately where it is not visible from the hallway for two of two residents (R3 and R7) in the sample reviewed for nursing care in the sample. This failure affected R3 and R7 whose urine drainage bag was without privacy bag and was visible from the hallway to other resident and visitors. Findings include: On 05/30/24 at 10:53am, R3 noted in bed with urine bag collection visibly noted from the hallway. When this observation was shown to V6 (Case Manager), V6 was asked about the facility policy and protocol on dignity and privacy. V6 stated that Urine bags (Collection Bags) should be inside a privacy bag. On 05/30/24 at 11:00am, R7 observed in bed with urine collection bag visible from the hallway with no in a privacy bag. At 11:02am, when this was shown to shown to V7 LPN (Licensed Practical Nurse), V7 was asked about the facility policy/ protocol on privacy and dignity. V7 stated that it (referring to the urine collection bag) should be covered with a dignity…

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 ensure that inhaler medication was labelled appropriately, was ordered by physician, and locked in a medication cart when not in visual proximity of the nurse and not in use to prevent tampering and hazard for two residents (R4 and R5) in the sample of 8 residents. Findings include: On 05/30/24 at 10:29am, R5 was observed in bed with inhaler medication noted on the over the bed table. Symbicort budesonide 80mcg, Formoterol Fumarate Dihydrate 4.5mcg inhaler aerosol 80/4.5 and Latanoprost (4 tubes) not in manufacturer's package, without a name or pharmacy label. R5 stated R5 uses the inhaler and needs it. At 10:32am, when this observation was shown to V21 LPN (Licensed practical Nurse) and was asked about the facility policy and protocol on professional standard of medication storage, and medication administration, V21 stated no medication should be left at the bedside unless it is ordered, and it should be labeled with name of the patient and administration direction. V21 said, I should get a plastic bag to put…

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 record review the facility failed to report an elopement of a cognitively impaired resident with an appointed state guardian to the Illinois Department of Public Health. This failure affected R2 wh0 eloped from the facility on 10/10/23. Findings include: R2's admission diagnoses include but not limited to schizophrenia, noncompliance with medications regimen, bipolar disorder, current episode depressed, severe with psychotic features and diabetes. R2's (10/10/23) BIMS (Brief Interview Mental Status) summary score blank. IDPH (Illinois Department of Public Health) was not notified of a cognitively impaired resident with a state appointed guardian elopement on 10/10/23. R2's progress notes on 10/9/23 at 6:47 am, V16 LPN (License Practical Nurse) documents, in part, R2 up at 5:00 am, wandering around unit, multiple warnings to not enter other resident's rooms, advised to sit in room or dining room. Perseveration regarding an outpatient pass. Advised to wait to 8/8:30am and speak with social services. Last seen seated at nurse's station at 6:30. R2's progress…

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 ensure food was served at a palatable temperature. This deficient practice has the potential to affect all 152 residents receiving food prepared in the facility's kitchen. Findings include: On 09/21/23 at 1:58 PM, R3 stated the hot food is always served cold by the time it is delivered to her and when R3 asks for staff to heat up her food they tell her they will but then they don't come back to do it. On 09/26/23 at 12:56 PM, R1 complained the hot food is not hot because the trays sit on the unit for a long time before they are passed out. R1 stated R1 can ask the staff to warm up R1's food but they are usually too busy passing out the trays to the other residents. R1 stated if the hot food was hot the food might taste better and cold food does not taste good. On 09/21/23 at 11:50 AM, V14 checked tray line temperatures as follows: Meatloaf 209.6 degrees Fahrenheit (F), Broccoli 150.2 degrees F, Mashed Potatoes 208.9 degrees F, Ground Meatloaf 157.8 degrees F, Pureed Meatloaf 168.8 degrees F, Pureed Broccoli 178…

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 provide a safe and sanitary environment. Findings include: On 9/21/23 at 1:22 PM, R3 stated the shower heads in the shower rooms are broken and are always leaking water from them and the floors have standing water on them even before R3 turns on the water which make the floors slippery. R3 says two days ago R3 slipped, lost her balance, and almost fell but was able to catch herself at the last minute. R3 stated there is nothing to keep the water inside the shower stall when in use so when taking a shower, the water from the shower stall flows into the middle of the shower room floor and sometimes into the hallway. R3 reports drain covering missing from one of shower stalls on the 4th floor and complained the shower stalls have mold in them. R3 stated there is black mold in the inside of the plastic spout of the ice machine on the unit. R3 stated, It's full of mold, I can see it and I'm allergic to mold. R3 stated, This is where I'm getting my water and ice from for hydration which means I am ingesting the mold…

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 provide a homelike environment to R3 by not providing privacy curtain in the shower stall. This failure resulted in R3 not being provided with a homelike environment at the facility. Findings include: On 9/21/23 at 1:22 PM, R3 stated there is missing shower curtain in the 4th floor shower room and there should be shower curtains for privacy because when someone comes into the shower room, they can see R3 naked. R3 stated, I should be allowed privacy when bathing. On 09/21/23 at 12:54 PM, V16 (Maintenance Worker) observed with surveyor missing shower curtain in the 4th floor shower room. V16 stated the shower curtain was taken down because it was damaged and another one should have been put up in its place. On 9/21/23 at 1:07 PM, V17 (Certified Nursing Assistant) observed missing shower curtain from the left shower stall in the 4th floor shower room. V17 stated the shower curtain has been missing for a while and the purpose of having a shower curtain is to provide privacy for the residents when they are taking a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and provide medically related social services to address alcohol dependence when in the community for one (R6) of three residents reviewed. Findings include: R6 is a [AGE] year-old, oriented, ambulatory male who was admitted to the facility on [DATE]. R6 hospital records dated 12/23/2022, prior to admission, documents R6 has alcohol dependence and reports drinking alcohol several times a week and binge drinking at least once a month. Facility Census dated 09/21/2023 documents R6 currently resides in the facility. The facility failed to identify and document R6 had a history of alcohol dependence and provide medically related social services. R6 went out on pass into the community and returned to the facility intoxicated. Nursing progress note dated 09/10/2023 at 6:36pm, documents, R6s' family called. Explained R6 was drinking due to loss of brother and other family members. That is the reason R6 was observed on the floor smelling of alcohol.…

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 prevent comingling of staff personal food items with facility food items in the kitchen's refrigerator. This failure has the potential to affect all resident receiving oral nutrition. On 6/11/2023 at 9:18am observed in the refrigerator a black plastic bag with food items, a lunch tote and a large bottle of coffee creamer. On 6/11/2023 at 9:20am V35 (Assistant Dietary Manager) stated those items (black plastic bag, lunch tote and large bottle of coffee creamer) belonged to the staff. On 6/12/2023 at 12:02pm V14 (Dietary Manager) stated, No it should not be stored refrigerator, it should be stored in the employee break room. Updated General Orientation Checklist and Acknowledgement documents, in part, during the facility tour-designated areas for lunch, breaks, personal item storage.

Based on observation, interview, and record review, the facility failed to maintain the fourth-floor bathroom wall tiles in good repair; failed to replace the missing shower knob in the community shower room; and failed to keep dryer lint compartments free of lint buildup. This failure has the potential to affect all 64 residents on the fourth floor and all 175 residents residing in the facility. Findings include: 1. On 6/11/23 at 10:30am during the entrance conference, the facility's administration presented the facility's census that shows that 64 residents live on the fourth floor. On 6/12/23 at 10:40am during observation on the fourth floor with V18 (RN/Registered Nurse Case Manager), the shower knob for the right-side shower stall on the fourth-floor shower room was observed to be broken and missing. Wall tiles were broken and missing on the right-side wall of the shower room. Inquired from V18 if the issues were noted on the Maintenance log records for the floor, V18 stated, she (V18) would notify Maintenance. V18 stated, This shower room is the only shower room for the fourth…

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 assess one resident (R26) for the ability to safely self-administer medication. This failure affected R26 and has the potential to affect all 45 residents residing on the 4th floor. Findings include: The (06/10/2023) Daily Census documented that there were 45 Active residents in 4th floor. R26's (Active Order as of 06/04/2023) documented, in part Diagnoses: Major Depressive Disorder, Anxiety Disorder, Dementia and Dysphagia (difficulty in swallowing). On 06/11/2023 at 11:19 AM, there was a medicine cup with medications on top of R26 bedside table. V4 (Licensed Practice Nurse) counted the medications in the medicine cup. V4 stated, Seven medications. We (facility) are not supposed to leave medications at bedside because we (facility) would not know if he (R26) would take them or not. On 06/13/2023 at 1:07pm, V16 (Licensed Practice Nurse/ADON) stated self-administration of medication must be care planned and ordered by the doctor. There should be education and assessment of the resident. The importance 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 observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions as indicated in the facility's policy, for residents at risk for pressure ulcers. This failure has the potential to affect 9 residents (R2, R34, R40, R44, R69, R77, R82, R95, and R163), reviewed for pressure ulcer prevention interventions. Findings include: 1. On 6/12/23 at 10:15am during observation of residents in the fourth-floor dining room, R2, R40, and R44 were observed in the dining room sitting in the wheelchairs without pressure relieving cushion devices as indicated in the facility's policy. V20 (CNA-Certified Nurse Assistant) was with the residents at the time. At 11:20am, all 3 residents were still in the wheelchairs without cushions. On 6/12/23 at 10:35am during observation of residents on the third floor, R34 and R163 were observed in the day room with V27 (Activity Aide). R34 and R163 were observed sitting in their wheelchairs without pressure relieving cushion devices. At 11:45am, both R34 and R163 were in the same position. V11(Unit Manager)…

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 record review, the facility failed to maintain shift change accountability records for controlled substances for residents'-controlled medications. This failure has the potential to affect one of four medication carts reviewed, and all residents on the second floor that receive medications from the medication cart. Findings include: On 6/12/23 at 2:50pm on the second floor with V23 (LPN/Licensed Practical Nurse), during observation of the medication carts, the Shift Change Accountability Records for Controlled Substances shows several missing entries of nurses' signatures. This is interpreted to mean there were some shifts no nurse was accountable or responsible for the narcotics on the floor. The missing entries for April 2023 include: 4/5/23, 4/11/23, 4/13/23, 4/16/23, and 4/30/23. The missing entries for May 2023 include: 5/7/23, 5/21/23, and 5/24/23. V23 was asked why some nurses did not sign the records and if they counted the narcotics before taking over from the previous nurse. V23 responded, she does not know whose signatures were missing, and she…

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 ensure handrails on the third floor were firmly affixed to the walls and failed to ensure the broken sharp edges of the handrails were fixed. This failure has the potential to affect all 64 residents on the third floor. Findings include: On 6/11/23 at 10:30am after the entrance conference, facility's administration presented the facility census which shows there are 64 residents on the third floor. On 6/12/23 at 11:05am during observation of residents on the third floor, the handrails by the elevator and on the right side of the hallway close to the nursing station were observed to be loose and broken at the edges with the sharp metal ends protruding. Maintenance log for the floor was requested from V19 (LPN/Licensed Practical Nurse). The Maintenance Log did not show any records of the broken and loose handrails. V19 explained to the surveyor, if any staff reported any maintenance issue, it will be on the maintenance log. V19 stated, No one reported it yet, I will write it on the log now, so maintenance will…

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 ensure the call light was within reach for a resident. This failure affected one resident (R106) reviewed for call lights, in a total sample of 66 residents. Findings include: R106's Face sheet documents R106 has the following diagnosis which includes, but are not limited to: type 2 diabetes, peripheral vascular disease, heart failure, anxiety disorder, essential hypertension, difficulty in walking, cellulitis of unspecified part of limb, unspecified abnormalities of gait and mobility, history of falling, unspecified osteoarthritis, sciatica, unspecified atrial fibrillation and emphysema. R106's Brief Interview for Mental Status (BIMS) dated 5/8/2023 documents R106 has a BIMS score of 12, which indicates R106's cognition is moderately impaired. On 6/11/2023 at 12:00pm surveyor observed R106 lying in the bed, covered with bedsheets and a blanket, alert and oriented. When asked, Where is your call light located?, R106 stated, I don't know, the call light is not in the bed with me, I don't see the call light. On…

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

Based on observation, interview and record review the facility failed to document the code status for one resident, R337. This failure has the potential to affect one resident in the sample of 66. Finding including: R337's has a diagnosis of but not limited to Dementia, Diverticulosis of Intestine, Heart Failure, Hypertension, Chronic Kidney Disease, Stage 3 and Altered Mental Status. R337's Brief Interview of Mental Status is 06 which indicates severely impaired. On 6/13/2023 at approximately 12:00pm surveyor reviewed R337's profile and orders screen. There was no code status documented. Surveyor reviewed R337's face sheet and the response area for Advance Directive was blank. On 6/13/2023at 1:09pm V18 (RN/Case Manager) stated, code status should be on the profile screen and the orders screen. V18 stated, she would put R337's code status in the system. On 6/14/2023 at 2:00pm surveyor reviewed R337's Order Summary Report with active orders of 6/13/2023 that did not include an order for R337's Advance Director or Code Status. R337's care plan dated 2/01/2023 documents, in part, R337…

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 ensure a resident who depends on staff's assistance for ADL (Activities of Daily Living) care and grooming received nail care. This affects one resident (R4) in the total sample of 66 residents, reviewed for ADL care and grooming. Findings include: On 6/12/23 at 11:35am, R4 was observed awake in bed with contractures on all extremities and long fingernails on both hands which had accumulated brownish black substances on the nail beds. On 6/13/23 at 11:32am, R4 was observed awake in bed with the fingernails still long and with accumulated dirt as observed on the previous day. On 6/13/23 at 1:33pm, V26 (Activity Director) stated, Activity Staff usually do nail care for residents and would find out why R4's nails were not trimmed and cleaned. R4's care plan dated 10/17/2015 with latest revision 12/2/2019 states R4 requires assist with ADL'S related to Impaired Mobility, Weakness, Rheumatoid Arthritis, Cerebral Palsy and has ADL self-care deficit, and requires assistance with ADL care and grooming: MDS (Minimal…

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 reviews, the facility failed to ensure residents' nasal cannulas and humidifier bottles were dated for 2 (R26 and R67) residents; failed to ensure the nasal cannula and humidifier bottle were not outdated for 1 (R53) resident; and failed to ensure humidifier bottles were filled with water for 2 (R26 and R53) residents. These failures affected 3 (R26, R53 and R67) residents reviewed for oxygen administration in the total sample of 66 residents. Findings include: 1. On 06/11/2023 at 11:19 AM, R26's humidifier bottle had no water and was not dated; the nasal cannula was also not dated. V4 (Licensed Practice Nurse) checked R26's humidifier bottle and nasal cannula per this surveyor's request and stated, the nasal cannula and humidifier bottle were not dated. V4 stated, These should be labeled with date. We (facility) want to make sure these were changed to prevent risk of infection. The humidifier bottle should have water for moisture. The night shift usually changes them. On 06/11/2023 at 11:21am, R26 stated, I (R26) need them (facility) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' expired eye drops were discarded; and failed to label opened multidose Insulin with the open date. This failure has the potential to affect 2 residents (R99 and R132), reviewed for medication storage, in a total sample of 66 residents. Findings include: 1. On [DATE] at 2:58pm during observation of medication carts on the second floor with V23 (LPN/Licensed Practical Nurse), R99's Alphagan Ophthalmic Eye drops (5 ml-milliliters) was observed to be opened, labeled with open date of [DATE] (5 months ago). V23 was asked for how long after opening the eyedrops are good for; V23 stated I think it should be discarded after 30 days. I believe there is a new bottle. 2. R132's 10 ml multi-dose vial of Insulin Glargine 100 units per ml was observed open with no open date. V23 stated the Insulin belongs to the second cart and they should have put the open date on the insulin when it was opened. On [DATE] at 1:04pm, V18 (RN/Registered…

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.