Lincoln Village Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain consent prior to administering psychotropic medications for one of three residents (R1) reviewed for psychotropic medications in a sample of 30.Findings include:The facility's Psychotropic Medication Policy, dated 2/2014, documents Policy: To establish the process for monitoring the use of and the Reduction of doses of psychotropic medications without compromising the resident's health and safety, ability to function appropriately, or the safety of others. Policy Specifications: Psychotropic medication shall not be prescribed without the informed consent of the resident, the resident guardian, or other authorized representative.R1's Face Sheet, dated 7/16/25, documents R1 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Intellectual Disabilities and Epilepsy.R1's current Physician Order Sheet documents R1 receives Risperidone (psychotropic medication) 0.5 mg (milligram) tablet twice a day and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of resident abuse to the State Agency and Administrator for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. V. Internal Reporting Requirements and Identification of Allegation: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance…

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 and interview the facility failed to immediately investigate an allegation of resident abuse for one of seven residents (R13) reviewed for Abuse in the sample of 30.Findings include:The facility's Abuse Prevention Policy, undated, documents The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. VII. Internal Investigation- 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. 8. Final Investigation Report: The investigator will report the conclusions of the investigation in writing to the administrator or designee within five working days of the reported incident.R13's MDS (Minimum Data Set) assessment dated [DATE] documents R13 is cognitively intact.On 7/16/25 at 2:45 PM R13 was lying in…

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

Based on interview and record review the facility failed to provide residents with a bed hold and written notice of transfer when transferring to the hospital for three of three residents (R3, R13, and R14) reviewed for hospital transfers in a sample of 30. Findings include: The facility's Transfer and Discharge Policy, un-dated, documents Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician orders, and in such a manner as to maintain continuity of care for the resident. Policy Specifications: 2. When the facility transfers or discharges a resident under any circumstances, the resident/authorized legal representative must be notified verbally and in writing at least 30 days prior to the intended discharge unless the resident waives the notification period or in an emergency. (including situations where the safety of other residents may be compromised). The facility must also: b. Include a written notice to the resident/authorized legal representative the following. i. reason for transfer/discharge; ii. Effective date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident received a consultation with a lymphedema specialist and a nephrologist, as ordered by the physician, for one of four residents (R26) reviewed for physician orders in the sample of 30. Findings include:The facility's Physician Orders Policy, dated 1/23/25, documents Procedures: 6. Nursing staff will follow physician orders. In an event where a resident refuses medication or treatment, or medication is not available, Physician or Nurse Practitioner will be notified.The facility's Transportation Policy, dated 6/21/2021, documents Policy: It is the policy of this facility to assist residents in obtaining transportation when necessary for services outside the facility. Standards: 3. Nursing or Social Service personnel or designee shall assist residents in obtaining transportation when it is necessary to obtain medical, dental, diagnostic, or other services outside the facility. Staff shall be familiar with requirements for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to update a pressure ulcer care plan and implement pressure relieving interventions for one of three residents (R1) reviewed for pressure ulcers in the sample of 30.Findings include:The facility's Prevention of Pressure Wounds Policy, dated 1/2025, documents Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. General Guidelines: 1. Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The Most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around th4 ears, elbows, should blades, backbone, hips, knees, heels, ankles, and toes. 5. Once a pressure injury develops, it can be extremely…

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 monitor an indwelling urinary catheter for urine output, urine color, and urine consistency, perform a voiding trial as ordered by a physician, follow-up with urology as ordered by a physician, and provide catheter care every shift for one of four residents (R4) reviewed for indwelling urinary catheters in the sample of 30.Findings include:The facility's Urinary Catheter Care Policy, dated 9/2005, documents Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract. Preparation: 1. Review the residents plan to assess for any special needs of the resident. 7. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Documentation: The following information should be recorded in the resident's medical record- 1. The date and tie that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving…

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 and interview the facility failed to update weight loss care plans with weight loss interventions for two of four residents (R1 and R16) reviewed for significant weight loss in the sample of 30.Findings include:The facility's Weight Assessment and Intervention Policy, dated 1/2025, documents The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- Five percent weight loss is significant; greater than 5% is severe. b. 3 months- 7.5 percent weight loss is significant; greater than 7.5% is severe. c. 6 months- 10 percent weight loss is significant; greater than 10 percent is severe. Care Planning: 2. Individualized care plans shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment.1. R1's Face Sheet, dated 7/16/25, documents R1 is a [AGE] year-old male that admitted to the facility on [DATE] with 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 record review and interview the facility failed to obtain a physician ordered Basic Metabolic Panel for one of five residents (R19) reviewed for laboratories in the sample of 30.Findings include:The facility's Physician Orders policy dated 1/23/25 documents, Nursing staff will follow physician orders.R19's current Physician Order Report documents, Start Date 1/15/25: Basic Metabolic Panel every Wednesday every two weeks.R19's Medical Record dated 1/15/25 documents R19 has only had a Basic Metabolic Panel laboratory obtained on 6/25/25, 7/2/25, 7/4/25, and 7/9/25. On 7/16/25 at 11:00 AM V19 (Regional Nurse Consultant) verified R19 did not have a Basic Metabolic obtained every two weeks as ordered on 1/25/25.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions during direct cares for one of five residents (R22) reviewed for infection control in the sample of 30.Findings include:The facility's Enhanced Barrier Precautions policy dated 01/2025 documents, Guideline: It is the practice of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents know to be colonized or infected with a MDRO (Multi-Drug-Resistant Organism) as well as those at increased risk of MDR acquisition. Implement Enhanced Barrier Precautions for residents with any of the following: Wounds and/or indwelling devices. High-contact resident case activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.R22's current Physician Order Report documents R22 has 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 interview and record review, the facility failed to follow its policy to ensure resident to resident physical abuse did not occur for one resident (R5) reviewed for abuse in a sample of four. Findings include: Facility's Abuse Policy, reviewed 5/19/25, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflected upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Facility's Initial and Final…

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 review, the facility failed to thoroughly investigate an allegation of resident to resident abuse for one resident (R8) reviewed for abuse in a sample of four. Findings include: Facility's Abuse Policy, reviewed 5/19/25, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This will be done by implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Reports will be documented, and a record kept of the documentation. VII. 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an…

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 and implement a treatment order for one resident (R3) and failed to follow its policy for labeling and dating wound dressings after treatments for two (R1, R6) residents reviewed for wound care/treatments in a sample of four. Findings include: The facility's Medication and Treatment Orders policy, Revised 7/2016, documents: 3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. The facility's Medication Orders Policy, Revised 11/2014, documents: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. A current list of orders must be maintained in the clinical record of each resident. 6. Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. The facility's Wound Care Policy, Revised 10/2010, documents: 13. Dress Wound. [NAME] tape with initials, time, and date and apply to dressing. The facility's Skin and Wound Management Policy,…

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 adequate staffing to deliver resident cares efficiently and in a timely manner. This failure has to potential to affect all 72 residents currently residing in the facility. Findings include: The Facility Assessment (reviewed 07/30/24) documents the following: The facility assessment must address or include the facility's resident population, including; but not limited to: Both the number of residents and the facility's resident capacity; The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. The Facility Assessment goes on to document: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and…

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

Based on observation, interview and record review, the facility failed to respond to resident call lights in a timely manner for seven of seven residents (R2, R3, R4, R6, R8, R9 and R10) reviewed for call light response time in the sample of 24. Findings include: The facility's 'Answering the Call Light' policy (dated August 2008) documents the following: The purpose of this procedure is to respond to the resident's requests and needs; General Guidelines: 8. Answer the resident's call light as soon as possible; Steps in the Procedure: 4. Do what the resident asks of you, if permitted; and, 5. If you have promised the resident you will return .do so promptly. The Facility Assessment (reviewed 07/30/24) goes on to document: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering 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 interview, observation and record review, the facility failed to remove and discard unlabeled multi-dose insulin vials and multi-dose insulin delivery pens from four active medication carts for 17 of 17 residents (R3 through R6, and R12 through R24) reviewed for insulin usage in the sample of 24. Findings include: The facility's undated Medication Administration policy documents: Medications shall be prepared and administered only to residents for whom they were ordered . The facility's Storage of Medications policy (effective 10/25/14) documents the following: All medications dispensed by the pharmacy are stored in the container with a pharmacy label. On 5/14/25 at 11:35 AM, an unlabeled, multi-dose vial of insulin was stored in the insulin compartment of the top drawer of the active medication cart for Harmony I hall. On 5/14/25 at 11:30 AM, V4 (RN/Registered Nurse) stated she would not use an unlabeled vial of insulin and any insulin pens or vials without an identifying label with the resident's name…

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 implement all components of their abuse policy for one of four residents (R1) reviewed for abuse in the sample of 24. Findings include: The facility's Abuse Prevention Policy (undated) documents the following Investigation Procedures: The appointed investigator will at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other submitted documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. R1's Abuse Investigation (dated 04/21/25) documents an abuse investigation was initiated after R1 verbalized an allegation of physical abuse to V15 (R1's wife). This investigation did not include documentation of any interviews obtained from residents who receive assistance from the same caretakers who provide care to R1. 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 interview and record review, the facility failed to thoroughly investigate an allegation of physical abuse for one of four residents (R1) reviewed for abuse in the sample of 24. Findings include: The facility's Abuse Prevention Policy (undated) documents the following Investigation Procedures: The appointed investigator will at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other submitted documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed. R1's current care plan documents the following focus: (R1) is an adult living with chronic health conditions, challenges, and co-morbidities and symptomatologic factors that require monitoring that put him at risk for abuse. This same care plan also documents the following focus: (R1) displays deficits in cognition, a BIMS…

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 and interview the Facility failed to provide weekly showers for seven of eight Residents (R1, R2, R3, R4, R5, R7 and R8) reviewed for showers in a sample of nine. Findings include: The Facility Shower/Tub Bath Policy, revised 8/2002, documents: the purpose of this procedure are to promote cleanliness, provide comfort to the Resident and to observe the condition of the Resident's skin; the following information should be recorded in the Resident's Activity of Daily Living/ADSL record and/or in the Resident's medical record (date/time of shower/tab bath, name/title of individual who assisted, assessment data, how Resident tolerated, if Resident refused and signature/title of person recording the data); report other information in accordance with Facility policy and professional standards of practice. The Facility Certified Nursing Assistant/CNA Position Title, undated, documents: assist nursing personnel in providing nonprofessional nursing care and simple technique nursing services;…

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 their Dietary Menu and provide condiments for six of nine Residents (R1, R2, R4, R5, R6, R7) reviewed for dietary preferences in a sample of nine. Findings include: The Facility Week at a Glance Dietary Menu documents condiments be served with the Breakfast, Lunch, and Supper meals. The Facility Dietary Purchase Orders, dated 3/3/25, 3/6/25, 3/10/25, 3/13/25, 3/17/25, 3/20/25 and 3/24/25, document one box of sugar substitute/sweetener was received on 3/10/25. No other substitute sugar/sweetener was purchased. R1's, R2's, R4's, R5's, R6's and R7's Continuity of Care Documents/CCD, document a diagnoses of Diabetes Mellitus. On 3/25/25 at 12:09 pm, 3/26/25 at 8:35 am, 3/26/25 at 12:20 pm and 3/27/25 at 8:25 am, no substitute sugar/sweetener was available/stocked on the dining room tables, individual serving trays or in the Main Dining Room condiment cart/bar. On 3/26/25 at 8:35 am and 12:20 pm, no substitute sugar/sweetener packets were observed on the room tray carts. On 3/27/25 at 9:48 am, no sugar…

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 respiratory equipment was dated, bagged, and kept off the floor per facility policy and professional standards for four (R20, R28, R39, and R125) of six residents reviewed for respiratory therapy in a sample of 26. Findings include: A facility procedure titled Respiratory Therapy, dated 11/2017, documents The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the procedure include, 2. Use distilled water for humidification per facility protocol. 3. [NAME] bottle with date and initials upon opening and discard after twenty four (24) hours. It also documents, e. Change the reservoir every forty-eight (48) hours and disinfect with 2%/percent alkaline glutaraldehyde or sterilize. Additionally, this procedure documents, 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula and tubing used prn (as needed) in a plastic bag when not in…

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

Based on observation, interview, and record review the Facility failed to employee a full time Director of Nursing. This failure has the potential to affect all 75 Residents residing in the Facility. Findings include: The Facility Daily Census Report, dated 12/24/24, documents 75 Residents residing in the Facility. The Facility Assessment Tool, dated 7/10/24, does not document a Director of Nursing. The Assessment also documents: that a Director of Nursing is needed to provide support and care for Residents; reviews the regulation for the Facility Assessment requirements; the Facility identifies the type of staff members and Nursing Services (Director of Nursing); and the Infection Control Committee is composed of the following personnel (Director of Nursing). The Facility Director of Nursing Job Summary, update 7/14/20, documents that the Director of Nursing will develop, monitor, and adapt as necessary the Facility's clinical program; keep the Facility prepared for State and Federal Inspections; and participate in the survey process with the Administrator and maintain current…

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 notify a family member of a resident fall for one (R1) of three residents reviewed for falls in the sample of eight. Findings include: The facility's Change in a Resident's condition or Status policy and procedure, dated 05/17, documents Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. Unless otherwise instructed by the resident, the nurse will notify the resident's representative when: The resident is involved in any accident or incident, including injuries of unknown source and There is a significant change in the residents' physical, mental or psychosocial status. The Fall Event for R1, dated 9/6/24 at 7:15 am, documents R1 self-reported she lost her balance, fell in her room, and hit her head during the night. This Event documents R1 with a knot on mid (middle) occipital region of her head. This Event does not document anyone was notified of R1's fall. The Progress Note for R1, dated 9/6/24 at 10:51 am, documents V13…

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 implement complete neurological assessments, provide continuous monitoring, and provide timely hospital transfer for one (R1) of three residents reviewed for quality of care in the sample of eight. Findings include: The Residents' Rights for People in Long-Term Care Facilities, dated 11/18, documents Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source. Your facility must provide services to keep your physical and mental health, at their highest practical levels. The facility's Change in a Resident's condition or Status policy and procedure, dated 05/17, documents the Nurse will notify the resident's attending physician when: the resident has a significant change in status, resident's treatment needs altered significantly, or is necessary or in the best interest of the resident. The nurse will record in the resident's medical record any changes in the resident's medical condition or status; and If…

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

Based on observation, interview, and record review the facility failed to provide safety during resident cares, keep supplies in reach, and do a thorough fall investigation for one (R6) of three residents reviewed for fall safety during cares. Findings include: The facility's undated Managing Falls and Fall Risk policy and procedures documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The facility's undated Resident Rights Statement documents Residents will be cared for in a manner and in an environment that promote maintenance or enhancement of each resident's quality of life, dignity, and aspect in full recognition of his or her individuality. The facility's undated CNA (Certified Nursing Assistant) job description,…

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 misappropriation of controlled substance medications for eight of ten residents (R2, R7, R9, R10, R11, R12, R13, and R14) reviewed for misappropriation of resident medications in a sample of 14. Findings include: The facility's Abuse Prevention Policy, undated, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but…

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 designate an Infection Preventionist onsite, who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program (IPCP) to prevent and control infections in the facility. This has the potential to affect all 72 residents living in the facility. Findings include: The Infection Preventionist Job Summary dated 2/13/20 states, The Infection Preventionist (IP) is responsible for overseeing the infection control program. The IP systematically collects and assesses data in collaboration with the team to provide therapeutic, evidenced based care. The IP works collaboratively with the team to develop plans of care and documents progress toward achieving defined outcomes. This position requires the knowledge of epidemiology and application of public health practices in the facility, with the goal of implementing effective and efficient procedures and policies to combat disease transmission among residents and staff. Responsibilities: 1. Keeping Infection section of EMR…

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 take and record the food temperature of foods on the tray line (steam table); check and record the wash and rinse temperatures and the Chlorine level on the dish machine; Check and record the amount of sanitizing solution in the sanitizer bucket; Keep cases of food off of the floor in the kitchen, walk-in cooler and walk-in freezer; Keep thawing raw meat in non-porous containers; store raw eggs on the bottom shelf to prevent contamination of ready to eat foods underneath the raw eggs; label and date all foods stored; use sanitizer wipes to clean the thermometer before and between uses and keep chemicals off of the floor and on shelves six inches off of the floor. This has the potential to affect all 69 residents living in the facility. Findings include: Observations of the kitchen were made on 3/24/24 from 10:00 AM to 12:30 PM. The document, Dietary Daily Rounds Audit, dated, 2021, states, Dry goods storage, all boxes stored six inches off of the floor; Dish machine, temperature accurate and recorded on the…

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

Based on interview and record review the facility failed to provide range of motion programming to residents with limitations in range of motion for 7 of 7 (R3, R11, R27, R52, R55, R57, R63) residents reviewed for limited range of motion in a sample of 69 residents. Findings include: 1. R3's current care plan documented R3 had ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential is at risk for an ADL self-care performance deficit, unable to come to a sitting position from supine and has an inability to transfer r/t (related to) generalized weakness and Quadriplegia, C5-C7 (Cervical) incomplete. On 3/26/23 a Physician's Order documented for R3 to maintain current ROM (Range of Motion) via PROM (Passive Range of Motion) exercise program to BLE (Bilateral Lower Extremities) for 15 repetitions as tolerated twice daily. R3's Point of Care History Restorative Nursing Passive Range of Motion flowsheet lacked documentation PROM was conducted as ordered: in January, 18 of 31 days; in February, 17 of 29 days; and in March, 15 of 25 days. 2. R11's current 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a resident with a physician ordered calorie supplement, care plan weight loss and ensure resident weights were being scheduled and documented for residents with high-risk diagnoses, fluid fluctuation and weight loss for five of eleven residents (R52, R55, R57, R63, R64) reviewed for nutrition in the sample of 30. Findings include: The facility's Weight Monitoring Guideline policy, dated 4/6/2018, documents Purpose: The facility measures and records weights to ensure accuracy and provide information for the evaluation of clinical status unless clinically contraindicated with physician justification. To provide guidance on timely consultation and weight parameters. Guideline: Residents will be weighed; documentation will be recorded in (electronic health record): Monthly by the seventh of each month. Anytime as needed with a change in condition or specified by NAR (Nutrition at Risk) committee. As specified by the physician 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 interview and record review, the facility failed to have a Practitioner Order For Life-Sustaining Treatment/ POLST in the Medical Record for one resident (R171) in the sample of 30. Findings include: The Advanced Directives and Care Plan Guidelines dated 11/28/17 documents It is the practice of the facility to establish, implement and maintain written guidelines for advance directives. The resident has the right and the facility will assist the resident to formulate an advance directive to their option. The facility will inform and provide resident with a written description of the facility's practice to implement advance directives. The resident has the right to accept, request, refuse and/or discontinue medical or surgical treatment and to participate in or refuse to participate in experimental research. D. All advance directive document copies will be obtained and located within the medical record. E. The advance directives are present within the medical record for the facility staff and physician. Findings include: On 03/25/24 01:28 PM, there was no Advance Directive…

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 identify and monitor targeted psychotic behaviors to warrant the use of Seroquel (antipsychotic medication) and attempt a gradual dose reduction of the medication in the past year for one of one resident (R36) reviewed for antipsychotic medications in the sample of 30. Findings include: The facility's (undated) Antipsychotic Drug Assessment and Monitoring policy documents Residents receiving antipsychotic medication will be monitored by nursing personnel utilizing a behavior monitoring form (unless the resident has a psychiatric diagnosis). Behaviors must present a danger to the resident and/or others or interfere with the resident's functional ability to warrant medication. Documentation will include: Documentation of each behavior. This policy also documents Criteria for Psycho-pharmacological Drug use: Dose reductions or re-evaluations performed: Antipsychotic drugs, every six months. The facility's (undated) Psychotropic Medications Policy documents This facility shall ensure that residents do not receive…

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 review, the facility failed to implement the abuse policy for a thorough investigation and suspension of an employee for an allegation of abuse for one resident (R2) of three residents reviewed for allegation of abuse in a sample of three. Findings include: The facility's (State) Abuse Prevention Policy Dated 10/24/22 also documents: VII. Internal Investigation. 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse,…

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 review, the facility failed to report allegations of abuse to the State Agency for one (R2) of three residents reviewed for abuse in a sample of three. Findings include: The facility's (State) Abuse Prevention Policy Dated 10/24/22 documents: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the (State) Department of Public Health immediately, but not more than two hours of the allegation of abuse. On 1/11/24 at 12:10 pm, V11 Respiratory Therapy Director stated that V8 Power of Attorney/POA to R2 first informed V11 on 1/4/24 that V8 needed to speak to V11; stated that he had concerns about males caring for R2. V11 stated that she immediately went to inform V1 Administrator who was in a meeting; stated that she notified V2 Director of Nursing/DON at that time. On 1/10/24 at 12:05 pm, V8 Power of Attorney/POA to R2 stated that he visits R2 each day at the facility; that he reported the 1/4/24 incident (male staff touching R2's breast) to (V1 Administrator) the same day R2 told him. On 1/11/24 at 10:20am, V1…

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 review, the facility failed to do a thorough investigation for an allegation of staff to resident abuse for one resident (R2) of three residents reviewed for abuse in a sample of three. Findings include: The facility's (State) Abuse Prevention Policy Dated 10/24/22 documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault including non-consensual or non-competent to consent sexual activity. The facility's (State) Abuse Prevention Policy Dated 10/24/22 also documents: VII. Internal Investigation. 1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation…

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 notify the resident's physician of an ordered pain medication not being acquired from pharmacy and a resident being in severe pain for one of three residents (R1)reviewed for pain in the sample of six. Findings include: The facility's Change in a Resident's Condition or Status policy dated 5/17, states The nurse will notify the resident's physician when: b. There is a significant change in resident's physical, mental or psychological status, c. There is a need to alter the resident's treatment significantly. 5. The Nurse will record in the resident's medical record any changes in the resident's medical condition or status. R1's Hospital Discharge Orders dated 11/27/23 at 11:21 a.m., states Start Norco (narcotic pain medication) 7.5/325 mg (milligram) 1-2 tabs every six hours as needed for pain. Stop Norco 5/325 mg 1 tab every twelve hours as needed for pain. R1's Medication Administration Record dated 11/25/23 through 11/30/23, documents R1 did not get…

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 and interview, the facility failed to ensure a resident was free from misappropriation of a narcotic pain medication for one of three residents (R1) reviewed for misappropriation in the sample of five. Findings include: The facility's Abuse Prevention Policy, dated 10/24/22, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This policy also documents Misappropriation of Resident Property means the deliberate misplacement, exploitation or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. The facility's Controlled Drug Policy and Procedure, dated 5/2017, documents Controlled drugs, as determined by the facility, are counted every shift by the nurse reporting on duty with the nurse reporting off-duty. The inventory of the controlled drugs must be…

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 failed to provide sufficient staff for care of its residents on the night shift. This has the potential to affect all 76 residents residing in the facility. Findings include: The facility's Staffing Policy, dated 11/2017, documents: Policy: Our facility provides adequate staffing to meet the needed care and services for our resident population. In addition, staffing will meet all operational activities as required; and, Policy Specifications: 2. Certified Nursing Assistants/CNAs are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. The Facility Assessment Tool, dated 12/7/21, documents: Staffing Plan. 3.2 Facility checks daily staffing needs based on census, skilled and non-skilled residents. Position: Nurses' Aides: 12 CNAs (Certified Nursing Assistants) 12 hour shifts. Agency Staff: Facility utilizes agency nurses and CNAs to meet daily staffing needs as needed. The facility's Certified Nursing Assistant Daily Staffing Schedules document: Saturday 9/30/23…

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 follow its policy to provide timely and palatable supper meals to three residents (R7, R8, R9) reviewed for meals in a sample of six. Findings include: The facility's Food Palatability-Hot Food Temperatures Policy, undated, documents: Policy: The healthcare community prepares and serves food and beverages that is palatable, attractive and at safe and appetizing temperature. The facility's Dining Room Meal Service Times document: Breakfast 7:30-9am, Lunch 1130-1pm, Supper 430-6pm. The facility's Resident Council Minutes, documents: 7/30/23 Dietary: Food not hot enough; 8/28/23 Old Business: Meal late on weekends; Dietary: Meals are still not hot; and 9/25/23 Dietary: Meals need to be getting out on time; dinners are getting served at 6:30/7:00pm; no hot plates. The facility Assessment Tool, dated 12/7/21 documents: Facility serves three meals per day in the main dining and on each floor as needed at 7:30am, 11:00am, and 5:30pm. The facility's Grievance Log 2023, documents: 8/6/23: Food was late. On 10/24/23 at 10:45 am, R7…

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 have a Dietary Manager to supervise the prevision of meals which has the potential to affect all 82 residents in the facility. Findings include: A Dietary Management Policy (undated) states, The Dietary Services Department shall be supervised and managed by a duly qualified and experienced Food-Service Supervisor. In addition, this policy states, A dietary management staff member shall be on duty at all times when the department is in operation and is responsible for supervision of all staff on duty. On 9/2/23 at approximately 9:00 a.m. V2 (Corporate Liaison) stated the facility does not have a Dietary Manager. A Meal Times policy (undated) documents the facility's noon meal will be served between 11:45 a.m. and 12:30 p.m. On 10/2/23 at 12:32 p.m. V8 (Prep Cook) was the only staff member in the kitchen and was sorting through resident menus. The kitchen had soiling consisting of paper and food debris covering most of the floor, counter spaces, stove top, and slicer. There were clean dishes stacked on a soiled…

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 have sufficient staff to carry out the meal preparation safely and effectively, keep the kitchen clean and sanitary, and to serve residents' meals on time. These failures have the potential to affect all 82 residents in the facility. Findings include: A Dietary Management Policy (undated) states, The Dietary Services Department shall be staffed with the appropriate numbers of properly trained personnel to provide each resident the diet that meets daily nutritional and special dietary needs and to carry out the functions of the dietary service. Personnel shall be scheduled to be on duty sufficient hours to assure proper preparation, serving and sanitation. A Meal Times policy (undated) documents the facility's noon meal will be served between 11:45 a.m. and 12:30 p.m. On 10/2/23 at 12:32 p.m. V8 (Prep Cook) was the only staff member in the kitchen and was sorting through resident menus. The kitchen had soiling consisting of paper and food debris covering most of the floor, counter spaces, stove top, and slicer.…

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 meals were served on time and as per the scheduled meal times. This failure has the potential to affect all 82 residents in the facility. Findings include: A Meal Times policy (undated) documents the facility's noon meal will be served between 11:45 a.m. and 12:30 p.m. On 10/2/23 at 12:32 p.m. the dining room was full of residents waiting on the noon meal. V8 (Prep Cook) was the only staff member in the kitchen and was sorting through resident menus. V7 (Cook) came into the kitchen from a back room and stated that V7 was the daytime cook. V7 stated that the facility does not have enough staff to cook, clean, organize the kitchen duties, and deliver food on time to residents. V7 stated that sometimes V5 (Certified Nurse Aide Manager) will come into the kitchen to help, however, the kitchen is not V5's normal department. V7 proceeded to perform cooking, plating of food, rinsing of noodles, finding plates and utensils, sorting through menus, and loading plates of food into the portable food carts, all in 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, interview and record review the facility failed to ensure the kitchen was clean, without food debris and spills on the floor, the slicer was covered and without food debris covering the stand, clean dishes were removed from the dish machine area and protected from splashes and food debris, food prep surfaces were clean, the grill was cleaned and free of grease and food debris, individual hand towels were available at the hand washing station, empty and full boxes were kept off the floor, a food temperature log was maintained and food temperatures on the serving steam table were monitored. These failures have the potential to affect all 82 residents in the facility. Findings include: A Hot Food Service Temperatures policy dated 5/8/18 states, 2. Food will be held in the steam table at 135F (degrees Fahrenheit) or above during tray assembly. 3. Food temperatures of food being held in the steam table will be recorded. A Food Services Safety Precautions Policy dated 2/2014 gives as its purpose, To assure that all personnel are aware of food preparation and serving…

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 a resident did not develop a shear pressure injury for one of three residents (R1) reviewed for pressure ulcers in a sample of eight. Findings include: A Pressure/ Skin Breakdown- Clinical Protocol dated 1/2017 states, The physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. A Centers for Medicare and Medicaid form 802 documents R1 does not have any pressure injuries. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is moderately cognitively impaired, requires extensive assistance of two people for bed mobility, is dependent on staff for transfers and personal hygiene; and has functional limitation in range of motion in both lower extremities. R1's care plan dated 8/17/23 instructs staff to use a wheelchair cushion as a pressure ulcer…

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 the wheels of a recliner were locked and a transfer safety belt was used during a resident transfer which affected one of three residents (R1) reviewed for transfers in a sample of eight. Findings include: A Transfer-Using a (Transfer Safety) Belt policy dated 5/2017 instructs staff to use safety transfer belts to transfer residents to and from the chair, to the bed, or toilet. This policy states, Nursing assistants will routinely have a gait belt immediately available to them during resident transfer. In addition, this policy instructs staff to ensure wheelchair wheels are locked or otherwise immobile. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is moderately cognitively impaired, requires extensive assistance of two people for bed mobility, is dependent on staff for transfers and personal hygiene; and has functional limitation in range of motion in both lower extremities. On 10/2/23 at 11:51 a.m. V11…

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's perineal area was cleansed from the front to the back for one of three residents (R3) reviewed for incontinence care in a sample of eight. Findings include: A Perineal Care policy dated 8/2008 states, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. In addition, this policy states, Wash perineal area, wiping from front to back. On 10/3/23 at 10:12 a.m. V18 (Certified Nurse Aide/CNA) was preparing to provide incontinence care to R3. V18 positioned R3 on her back then removed R3's pants and removed the tapes on either side of R3's incontinence brief. V18 used a wet soapy washcloth to wipe from the back of R3's perineal area to the front. When V18 began cleansing R3's perineal from the back to the front, fecal material could be seen on the washcloth where V18 had dragged the fecal material from R3's buttocks area to the front across R3's urethra to the front of R3's…

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 hand hygiene was performed in between tasks during incontinence care for three of three residents (R1, R2, R3) reviewed for infection control practices in a sample of eight. Findings include: A Hand-Washing/Hand Hygiene Policy dated 3/2020 states, It is the policy of the facility to assure staff practice recognized hand-washing/hand hygiene procedures as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand rubs (ABHR) can be used for hand hygiene when hands are not visibly soiled or contaminated with blood or bodily fluids. This policy instructs that when hands are not visibly soiled they may use perform hand hygiene using ABHR in situation that include before direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, before and after putting on and taking off gloves, after contact with a resident's intact skin, after contact with objects in the immediate vicinity of a resident that may…

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 provide the services of a registered nurse eight hours a day, seven days a week. This failure has the potential to affect all 79 residents residing in the facility. Findings include: The facility's Staffing Policy dated November 2017 documents the facility will provide adequate staffing to meet the needed care and services for the resident population. This policy also documents that the facility maintains adequate staffing on each shift to ensure that residents' needs and services are met, and documents Licensed Registered Nursing staff are available to provide and monitor the delivery of resident care services and supervision to Certified Nursing Assistants/CNAs and other support staff. The facility's Facility Assessment Tool reviewed 7/31/23 documents the facility with an average daily census of 82 residents. The facility's Nurse's Daily Assignment Sheets document the facility did not have eight consecutive hours of registered nurse (RN) coverage in the building to provide services on the following dates: 7/8/23; 7/9/23;…

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 clean, homelike environment for one of three residents (R1) reviewed for clean, comfortable, homelike environment in the sample of three. Findings Include: The facility's Housekeeping Services Policy undated documents it is the policy of the facility to maintain a clean, comfortable and orderly environment in all healthcare and public areas and documents resident rooms are to be maintained in a sanitary manner. This same policy states, 4. The department shall routinely clean the environment of care, using accepted practices, to keep the facility free from offensive odors, the accumulation of dust, rubbish, dirt and hazards. The facility's Resident Rights Statement undated documents the facility will provide a safe, clean, comfortable and homelike environment. On 9/2/23 at 12:08 PM, V3 (R1's Family Member) stated there had been a bleach smell outside of R1's room for a few days. V3 stated V3 was informed the room next door to R1's room had mold and needed to be deep cleaned. V3 stated V3 had noticed…

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 a resident who requires assistance with activities of daily living was showered weekly and failed to ensure a resident's clothing was changed daily for one of three residents (R1) reviewed for activities of daily living/ADLs in the sample of three. Findings Include: The facility's Shower/Tub Bath Procedure revised August 2002 documents the purpose of the procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. This same procedure documents the following information should be recorded in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., a reddened area, sores, etc. on the resident's skin) obtained during the shower/tub bath. 4. How the resident tolerated the shower/tub bath. 5. If the resident refused 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 observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions for a resident with known skin impairments, failed to ensure pressure ulcer dressing changes were completed as ordered by the physician, failed to complete weekly wound assessments, and failed to notify the physician of a change in a resident's wound status for two of three residents (R1 and R2) reviewed for pressure ulcers in the sample of three. Findings include: The facility's Wound Care Policy, revised May 2017 documents the following: follow physicians' orders for wound care; documentation of wound care must be completed each time the treatment is done on the Treatment Administration Record (TAR); current wound status must be documented no less than once per week and documented in the resident's medical record; wound changes and other pertinent observations must be documented in the nurse's notes as they occur; the physician must be notified of change in the wound status; and 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 interview and record review, the facility failed to stay at a resident's bedside to ensure a resident consumed all of their morning medications during medication pass for one of three residents (R1) reviewed for medications in the sample of three. Findings include: The facility's Medication Administration Policy updated March 2022 documents residents shall not be left alone until the prepared medications are consumed or refused. R1's current Medication Administration Record/MAR documents orders for the following medications were scheduled for 8:00 AM on 8/28/23: Aspirin 81 milligrams (mg) once a day; Carvedilol 3.125 mg two tabs twice a day; Coenzyme Q10 100 mg four capsules once a day; Culturelle Capsule 15 billion cell one capsule once a day; Cyanocobalamin 400 micrograms (mcg) once a day; Cyclobenzaprine 10 mg three times a day; Diltiazem Hydrochloride 24 hour extended release 120 mg once a day; Gabapentin 200 mg three times a day; Glipizide 10 mg once a day; Hydrocodone-Acetaminophen Schedule II tablet 5-325 mg one tablet three times a day; Januvia 100 mg tablet once 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, interview, and record review, the facility failed to date open food items, store dry food on shelves, maintain clean equipment, and clean the kitchen between meals. This has the potential to affect 64 of the 71 residents residing in the facility. Findings include: The facility's Food Storage policy dated 2020 documents Food shall be stored on shelves in a clean dry area free from contaminants. On 4/16/23 at 7:00 AM, during the initial tour of the kitchen, the following observations were made: The kitchen refrigerator has ranch dressing, salad dressing (mayonnaise), and cottage cheese opened and not dated. The griddle has a black looking sludge along the front of the grease drain as well as food splattered on the side of the warmer sitting next to the griddle. There is dried food on the oven door and on the racks in the plate warmer. The dry storage has nine boxes of food sitting on the floor. On 04/16/23 at 7:02 AM, V10 (Lead Cook) verified the open food items in the refrigerator and stated, Those should be dated. We'll have to throw them out since they aren't…

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 wear Personal Protective Equipment (face masks) in compliance with the local Community COVID Outbreak Transmission Rate. This failure has the potential to affect all 71 residents residing in the Facility. Findings include: Facility Community Transmission Level Report, dated 4/14/23, documents a community Transmission Level of High. Facility COVID-19 Source Control and Personal Protective Equipment/PPE Policy and Procedure, undated documents: when the COVID-19 Community Transmission rate is High, source control is recommended for everyone in a health care setting when they are in areas of the health care facility where they could encounter Residents; and when the Community Transmission rate is High, HCP must wear a well-fitted mask at all times while in areas of the facility where they may encounter residents and eye protection should be worn during all resident care. On 4/16/23 at 5:56 am through 7:20 am, V7 (Licensed Practical…

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 indwelling urinary catheter tubing and urinary drainage bags were kept off the floor for four residents (R19, R61, R62 and R63) and ensure an indwelling urinary catheter drainage bag was maintained below the bladder for one out five residents (R64) reviewed for indwelling urinary catheters in a sample of 30. Findings include: 1. R63's Physician Order Sheet, dated 3/17/23 through 4/17/23, documents: diagnoses including kidney disease and Urinary Retention; indwelling urinary catheter size of 16 with a ten cubic centimeter/cc balloon; indwelling urinary catheter care (Foley) and catheter change every four weeks; and monitor output every shift. On 04/16/23 at 06:42 am, R63 was lying in bed and R63's indwelling urinary catheter drainage tubing and drainage bag were laying on floor next to R63's bed, with no dignity bag. On 4/19/23 at 9:59 am, R63 was in the therapy room and R63's indwelling urinary catheter tubing was lying on the floor. 2. R64's Physician Order Sheet, dated 3/17/23 through 4/17/23,…

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 conduct an assessment and include alternative interventions attempted prior to initiating the use of side rails for four out of four residents (R19, R33, R58 and R62) reviewed for side rails in the sample of 30. Findings include: 1. R33's Physician Order Sheet, dated 3/17/23 through 4/17/23, documents an order for bilateral quarterly upper bed rails for increased independence in bed mobility and repositioning. R33's Side Rails Observations & Consent Form, dated 8/24/21, documents R33's reason for top-half bed rail usage as bed mobility. The form does not document an assessment for alternate interventions prior to the initiation of the bilateral side rails. On 4/18/23 at 2:10 pm, V1 (Administrator) stated, We do not have any therapy documentation or prior intervention trials that were initiated for (R19, R33, R58 or R62) before their bed rails were initiated. I cannot find any documentation in their charts or the electronic record. We changed our therapy company and I emailed the old company to see if they can…

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 a clean homelike environment for one resident (R19) out of 30 residents reviewed for environment in a sample of 30 Findings include: R19's Brief Interview of Mental Status (BIMS) documents a score of 15. A score of 13-15 indicates an individual is cognitively intact. On 04/16/23 at 8:51 AM, during initial interview of R19, this surveyor stepped on tortilla chips that are on the floor between R19's bed and window. R19 stated, Those are from last night's dinner. Upon further observation of R19's room, the base boarding outside of R19's bathroom is coming off the wall, and there is a hole in the wall above where the base boarding is coming off. In the middle of the room, there are what appear to be four strips of left-over glue residue from something that was adhered to the floor and what appears to be tan-colored paint spots on the floor in the entryway. R19 nodded not when asked if he felt as though his room had been cleaned. The facility's dinner menu for 4/15/22 documents Chicken taco salad and…

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

Based on observation, interview, and record review, the facility failed to provide a written notice of transfer for two (R44 and R49) of two residents reviewed for hospitalization in the sample of 30. Findings include: 1. The Progress Notes for R44, dated 12/19/22 and 1/29/23, document R44 was transferred from the facility to a local hospital for evaluation and treatment. R44's Medical Record does not contain documentation of R44 or R44's Representative being provided written notice of reason for R44's transfers to the hospital. 2. The Progress Notes for R49, dated 8/2/22, 9/6/22, 11/7/22, 1/30/23, 2/2/23, and 3/8/23, document R49 was transferred to a local hospital for evaluation and treatment. R49's Medical Record does not contain documentation of R49 or R49's Representative being provided a written notice of reason for R49's transfers to the hospital. On 4/18/23 at 2:26 pm, V2 (Director of Nursing/DON) stated the Physician, DON, Administrator and Responsible Party are notified if a resident is sent out to a local hospital. V2 DON also stated, We do not put in writing a written…

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 complete an admission wound assessment, obtain a physician's order, and complete treatments for wounds for one resident (R319) of two residents reviewed for wounds in a sample of 30. Findings include: R319's medical record documents R319 admitted to the facility on [DATE]. R319's medical record documents diagnoses of peripheral vascular disease, calciphylaxis, diabetes and end stage renal disease. R319's skin observation dated 4/12/23 documents Open areas: Yes, describe - right hip, right lateral leg, left hip, sacrum, left stump, posterior left leg, right buttock On 4/16/23 at 8:40 AM, R319 stated, I don't think they're doing all my wound treatments. On 4/16/23 at 8:43 AM, V8 (Certified Nursing Assistant/CNA) lifted R319's right leg. R319 has a wound to her right distal lateral shin that is not covered, causing fluid to seep from the wound through to the sheet. V8 then pulled back R319's sheet to expose her left leg. R319's left leg has…

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 concentrators included humidification per physician order for one out of two residents (R28) reviewed for oxygen in a sample of 30. Findings include: R28's physician order sheet dated 9/06/2021 documents Oxygen: Change tubing and humidifier weekly and as needed. R28's brief interview of mental status (BIMS) documents a score of 15. A score of 13-15 indicates an individual is cognitively intact. R28's medical record documents diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure with hypercapnia. On 4/16/23 at 6:33 AM, R28 observed in his room with oxygen tubing in place via nasal cannula and connected to an oxygen concentrator set at 3.0 liters of oxygen per minute. The humidifier bottle is dated 3/26/23 and does not contain water. R28 stated, Yeah, that happens around here. When the water runs out, it causes my nose to dry out. On 4/16/23 at 7:35 AM, V2 (Director of Nursing/DON) stated, The bubble pack (Humidifier bottle) and tubing gets changed every seven days.…

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 assess and identify potential triggers for a resident with a diagnosis of PTSD (Post-Traumatic Stress Disorder) and failed to provide specific personalized interventions for a resident with a diagnosis of PTSD for one of two residents (R36) reviewed for mood and behavior in the sample of 30. Findings include: R36's Face sheet documents R36 admitted to the facility on [DATE] with a diagnosis of PTSD (Post Traumatic Stress Disorder). R36's Antipsychotic Medication Nursing Assessment, dated 2/2/23, documents this is an annual assessment and documents R36's diagnoses of PTSD, Paranoid Personality Disorder, Generalized Anxiety Disorder, and Panic Disorder. R36's Physician Order Report, dated 4/1/23-4/18/23 documents the following orders: Ativan 0.5 milligram/mg tablet for anxiety with an order start date of 10/10/22; Sertraline 100 mg daily for depressive episodes; Seroquel 200 mg at bedtime for Paranoid Personality Disorder; and Melatonin 3…

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 residents received medications as physician ordered for one (R58) of one resident reviewed for medication errors in the sample of 30. Findings include: The Event Report for R58, dated 4/2/23 documents V15 (LPN/Licensed Practical Nurse) gave an incorrect dose of Doxazosin 2 mg (milligram) to R58 by giving R58 two tablets equally 4 mg. V14 identified the medication error on 4/2/23, approximately 15 hours after the medication error occurred. On 4/18/23 at 7:25 am, R58 stated V15 (LPN) gave him two blood pressure pills and he should have only gotten one. R58 stated V15 came into his room, handed R58 the medications, and left R58's room. R58 stated his girlfriend took a picture of the medications after V15 left his room because R58 got more pills than he usually did. R58 stated he asked V14 (LPN) the next day what medicines he was supposed to get at 8:00 pm and told V14 he got the wrong medications. The Physician Order Report for R58, dated 3/19/23 through 4/19/23, lists a Physician order for 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.