Waters Of Dillsboro-Ross Manor, The

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity related to Activities of Daily Living (ADL) care and monitoring inventory of personal belongings for 4 of 9 residents reviewed for resident rights. (Residents B, C, K, and L) Findings include:1. During an interview and observation, on 07/17/25 at 10:17 A.M., Resident B indicated she was bruised during ADL care a couple of weeks ago. Staff members had come into her room early in the morning, after breakfast, and said she was going to take a shower. The resident held onto the grab bar on the side of the bed and kept saying she refused. The staff peeled her fingers off her side grab bar and proceeded to use the mechanical lift, transferred her to a shower chair, and forced her to take a shower. The resident indicated she was just bruised on her hands. There were no visible bruises observed to the resident's hands. The resident indicated she gave one of the aides a good titty twister when they got one of her hands loose, she should not have touched the aide, she was just…

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 treat and identify pressure ulcers in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident C)Findings include:During an observation, on 07/18/25 at 10:19 A.M., Qualified Medication Aide (QMA), answered Resident C's call light. The resident indicated she needed to get off the bed pan. The Assistant Director of Nursing (ADON) assisted the QMA to get the resident off the bed pan. The ADON cleansed the resident and left the room. She returned with a cream and applied it to the resident's bottom. She told the resident she didn't put the cream on her wounds just around them because the wounds would need a treatment put in place. The resident had a wound to the right posterior thigh that was pink in color with to drainage. The wound was pea size and did not have a dressing in place. The resident also had a wound on the coccyx that was a slit that was approximately the size of pencil lead. The wounds were shown by the ADON. The staff applied a brief and dressed the resident with pants. The…

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

Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to Enhanced Barrier Precautions (EBP) for 2 of 2 wound care observations. (Residents C and F) Findings include:1.During an observation, on 07/18/25 at 11:01 A.M., the Assistant Director of Nursing (ADON) entered Resident C’s room and indicated that she was going to apply a dressing to her wounds. The resident was rolled to her left side, her pants and brief were removed, and a treatment was applied to the resident’s right posterior thigh. The resident’s brief was reapplied, her pants were pulled up, and the resident’s full body mechanical lift pad was hooked up to the lift. The nurse was questioned about the coccyx wound not having a treatment in place at that time. The ADON nor the Certified Nurse Aide (CNA) in the room had donned gowns prior to the treatment of the right posterior thigh wound. During an observation, on 07/18/25 at 11:15 A.M., the ADON returned to the resident’s room and applied the treatment to the coccyx. The ADON nor the CNA had donned gowns…

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

Based on observation, record review, and interview, the facility failed to ensure staff supervised a resident that resided on a secured unit when off the unit for 1 of 3 residents reviewed for accident hazards. (Resident C) Findings include: Upon entering the facility on 06/16/25 at 4:25 P.M., on the first floor of the facility, there were no staff observed anywhere on or near the outside of the locked unit. There were three residents sitting in the dining room, outside the locked unit, including Resident C. There was an exit door approximately 10 feet to the right of where Resident C was sitting. During an observation, on 06/16/25 at 4:30 P.M., Dietary Staff 15 knocked on the dementia unit door and no staff answered the door. The door had a window that was approximately four feet by four feet and was 4.5 feet high. The dietary staff member indicated she was unsure of what the code was to get into the locked unit. The dietary staff left the area and then went upstairs to the second floor. Resident C was still sitting in the dining room outside the dementia unit with no staff…

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 provide medications in a timely manner for 1 of 3 residents reviewed for pharmacy services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/16/25 at 5:30 P.M. A Quarterly Minimum Data Set (MDS) Assessment, dated 04/11/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, and malnutrition. A physician's order, dated 04/16/24 through 05/29/25, indicated the staff were to administer the resident's Cyproheptadine (an antihistamine) 4 milligrams, three times a day for itching. The May 2025 Electronic Medication Administration Record indicated the resident did not receive the medication on the following dates and times due to it nor being available: From 05/19/25 through 05/23/25 for the 8:00 A.M. dose and the 2:00 P.M. dose. The clinical record lacked documentation that the physician was notified that the resident's medications were not available. During an interview, on 06/17/25 at…

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

Based on record review and interview, the facility failed to obtain a STAT x-ray in a timely manner for 1 of 3 residents reviewed for radiology services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/16/25 at 5:30 P.M. A Quarterly Minimum Data Set (MDS) Assessment, dated 04/11/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, and malnutrition. A Progress Note, dated 05/23/25 at 6:15 P.M., indicated the resident was noted to have some swelling and discoloration to the right lower leg. The Nurse Practitioner (NP) was notified, and a new order was obtained for a STAT (immediately) x-ray of the knee, ankle, and extended tibia/fibula. A Progress Note, dated 05/24/25 at 12:40 P.M., indicated the resident's x-ray was obtained and a new order was received to send the resident to the local emergency room. A Radiology X-Ray Report, dated 05/24/25 at 12:23 P.M., indicated the resident had a two view, right tibia and fibula x-ray. During 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 record review and interview, the facility failed to document a resident's behaviors for 1 of 3 residents reviewed for medical records. (Resident B) Findings include: During an interview, on 06/16/25 at 6:46 P.M., Certified Nurse Aide (CNA) 5 indicated Resident B had been having more behaviors during care for the last two to three weeks related to kicking her legs. The CNAs didn't have access to document a resident's behaviors. The CNAs had to let the nurse know and the nurse would document on the resident's record. She had told Licensed Practical Nurse (LPN) 4 and LPN 6 about the resident's behavior related to kicking her legs. During an interview, on 06/17/25 at 10:40 A.M., LPN 4 indicated the resident had some behaviors of kicking during care. The resident behaviors would be documented in the Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) or a progress note. During an interview, on 06/17/25 at 11:39 A.M., the Assistant Director of Nursing (ADON) indicated after interview staff, from 05/24/25 through 05/29/25. It was…

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

Based on interview, and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 3 residents reviewed. (Resident D) Finding included: A Progress note, dated 04/13/25 at 5:58 P.M., indicated Resident D was hitting, pinching, and spitting at staff during care. The resident was wanting to be left alone. The resident was cleaned up and the call light was given to the resident. A Significant Change Minimum Data Set (MDS) assessment, dated 3/5/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, non-Alzheimer's dementia, anxiety, and depression. The current Care Plan, dated 4/25/22, indicated Resident D was declining. The resident had episodes of declining resident care, medications, treatments, and refused showers. The interventions included, but were not limited to the following: - If resident continues to decline have another staff member approach. - if resident declines, make resident safe and leave; and reapproach in five minutes. During an interview, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store medications appropriately related to vials of insulin for 2 of 3 medication carts reviewed. (Station 3 Medication Cart 2 and Station 2 Medication Cart) Findings include: 1. Medication Cart 2 on Station 3 was observed on [DATE] at 9:23 A.M., with Licensed Practical Nurse (LPN) 2, and included the following: - A Fiasp/Aspart insulin vial for Resident 3, that was 1/4 full. The delivery date on the storage bottle was [DATE]. No open date was on the vial or the storage bottle. The LPN indicated the resident received the insulin four times a day per a sliding scale, but he had not received it yet that day. - A Lispro insulin vial for Resident 64, that was 3/4 full. The delivery date on the storage bottle was [DATE]. No open date was on the vial or the storage bottle. The LPN indicated the resident no longer used the insulin and it should have been removed from the cart. The clinical record for Resident 64 indicated his Lispro insulin had…

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 follow the physician's orders related to medication hold parameters (Resident 13) and implement fall interventions of non-skid strips (Resident 54) for 2 of 20 residents reviewed for Quality of Care. Findings include: 1. The clinical record for Resident 13 was reviewed on 03/05/25 at 10:26 A.M. An Annual Minimum Data Set (MDS) assessment, dated 01/15/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, dementia, anxiety, and depression. A current open-ended physician's order, with a start date of 01/08/25, indicated the resident was to receive Losartan (a blood pressure medication) 25 milligrams (mg), one time a day. The staff were to hold the medication when the systolic blood pressure (SBP) was less than 110 or the diastolic blood pressure (DBP) was less than 70. The January and February 2025 Electronic Medication Administration Record (EMAR) indicated the resident received the medication when the blood pressure was either…

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 promptly identify and treat a pressure wound infection in a timely manner for 1 of 3 residents reviewed for pressure ulcers/skin impairments. (Resident 64) Findings include: An admission Minimum Data Set assessment, dated 08/23/24, indicated Resident 64 was cognitively intact. The resident's diagnoses included, but were not limited to, non-traumatic spinal cord dysfunction, heart failure, multi-drug-resistant organism infection, diabetes, paraplegia, and malnutrition. The resident was at risk for pressure ulcers and had an unhealed Unstageable (Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer upon admission. The resident utilized pressure reducing devices for the bed and chair, and pressure ulcer treatments were administered. A Skin and Wound Note, dated 08/19/24, indicated the resident's prior…

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 ensure a resident's food preferences were identified and replacement meal options were offered for 1 of 3 residents reviewed for nutrition. (Resident 76) Findings include: During an interview, on 03/03/25 at 11:19 A.M., Resident 76 indicated he was recently admitted to the facility, and he did not like the food. They brought him eggs and sausage for breakfast, and sometimes oatmeal. He did not like to eat any of those things for breakfast. He was used to eating dry cereal with milk and fruit every day for breakfast at home. He liked to drink his coffee with his breakfast, not before breakfast. They always brought it before the meal, and it was cold by the time he got the food. He just didn't eat breakfast anymore. No one ever came and asked him about what food he liked or didn't like. He had been there a little over two weeks. During an interview on 03/04/25 at 10:27 A.M., the Dietary Manager indicated when a resident was admitted to the facility she would usually go and talk to them within a few days to find out what they…

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's medications were available for 1 of 5 residents observed for pharmacy services. (Resident 33) Findings include: Medication administration was observed on [DATE] at 10:56 A.M., with Licensed Practical Nurse (LPN) 4. As the nurse prepared medications for Resident 33, she discovered the resident did not have the physician prescribed Gabapentin 200 milligrams (mg) available. The resident was to receive two 100 mg tablets. The LPN indicated they had gotten a big shipment of medications that morning. The LPN indicated they would do a refill request, and the medication would come in that night. The resident was to receive Gabapentin 200 mg at 11:00 A.M. and at 4:00 P.M. The LPN checked the resident's record and indicated the resident's 200 mg dose was ordered on [DATE] and had not been reordered since. The medication cards usually held 30 pills. She did not know where the list was indicating what medications were delivered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain a wound culture in a timely manner for 1 of 2 residents reviewed for infections. (Resident 64) Findings include: Resident 64's clinical record was reviewed on 03/05/25 9:57 A.M. An admission Minimum Data Set assessment, dated 08/23/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, non-traumatic spinal cord dysfunction, heart failure, multi-drug-resistant organism infection, diabetes, paraplegia, and malnutrition. The resident was at risk for pressure ulcers and had an unhealed pressure ulcer upon admission. A Skin and Wound Note, dated 12/09/24, indicated the resident's sacral wound measured 8.2 cm x 8 cm, with a depth of 1.4 cm. The wound base was 90% granulation and 10% slough. There was a mild odor after the wound was cleansed. A Progress Note, dated 12/09/24, indicated there was a new physician's order to obtain a wound culture. The Lab Results Report for the wound culture ordered…

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 follow appropriate infection control guidelines related to hand hygiene for 2 of 6 residents observed during medication administration. (Residents 52 and 7) Findings include: Medication administration was observed on Station 3 on 03/04/25 at 1:36 P.M., with Licensed Practical Nurse (LPN) 4. The nurse prepared a medication, Gabapentin 300 milligrams, at the medication cart in the hallway for Resident 3. The LPN took the medication into the resident's room in a medication cup. The resident had limited use of his hands, and the nurse assisted the resident by moving his straw. The resident's straw was in his personal water bottle. The LPN continued to assist the resident with adjusting his foot pedals and applying the brakes on his wheelchair. The nurse went back to the medication cart, picked up a medication cup, expelled a dose of Carbidopa/Levodopa into a cup for Resident 52, poured water into a plastic cup, put a straw into the cup, closed the medication cart, and locked it. While administering the medication to Resident 52,…

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, observation, and record review, the facility failed to provide activities for 1 of 4 stations reviewed. This had the potential to affect 13 of 68 resident residing in the facility. (Memory Springs-Dementia Unit) Findings include: During an interview on 03/21/24 at 9:53 A.M., a family member indicated the Memory Springs Station never had any activities. During a continuous observation on 03/26/24 from 10:06 A.M. through 11:45 A.M., the following was observed: - at 10:06 A.M. two residents were asleep in recliners, and four residents in the dining room, staff were present and talking with a couple of the residents, - at 10:33 A.M., there were four residents in the dining room. Two of the residents were sleeping, 1 resident was eating a snack, and another resident was looking at pictures. The activity calendar was observed hanging on a bulletin board and indicated the resident's were to fold laundry at 10:30 A.M. - at 10:43 A.M., 1 resident left the dining room and there was a CNA (Certified Nurse Aide) in the common area. There was no staff engaging residents 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 and interview, the facility failed to provide a homelike environment related to odors for 1 of 4 stations reviewed. This had the potential to affect 13 of 68 resident residing in the facility. (Memory Springs-Dementia Unit) Findings include: During an observation on 03/20/24 at 9:51 A.M., there was a strong urine odor when entering Memory Springs. During an observation on 03/21/24 at 10:50 A.M., there was a strong urine odor in the common area of Memory Springs. The common area had seven recliners with cloth pads covering the seats. There were two recliners with residents sitting in them, asleep. During an observation on 03/22/24 at 1:41 P.M., there was a urine odor when entering Memory Springs, there were a few residents in the dining room. The common area had several recliners with cloth pads on the seats. The common area was open to the dining room. During and observation on 03/26/24 at 10:06 A.M., the common area in Memory Springs had a urine odor, there were several recliners with cloth pads on them. During an interview on 03/26/24 at 2:31 P.M., 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, observation, and record review, the facility failed to develop a care plan related to dentures for 1 of 20 residents care plans reviewed. (Resident 37) Findings include: During an interview on 03/21/24 at 10:01 A.M., a family member indicated Resident 37 had dentures, but he usually didn't have them in. He had kept playing with them and someone took them away and never offered them back. During an interview on 03/22/24 at 9:29 A.M., the resident was assisted out of bed by nursing staff member. The resident was assisted to his wheelchair and propelled to the hallway. He was not wearing his dentures. The resident indicated he was unsure of where his dentures were. During an observation on 03/22/24 at 9:32 A.M., the resident was offered a snack and accepted it. He did not have his dentures in and had not been offered them. He proceeded to eat his snack without difficulty. During an observation on 03/22/24 at 11:33 A.M., the resident was sitting at the dining table and served his lunch. The tray was a regular diet. He was eating and was not wearing his dentures. 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 provide routine bathing for 1 of 3 residents reviewed for ADL (Activities of Daily Living) care. (Resident B) Findings include: During an observation in the dining room on 03/20/24 at 11:24 A.M., a staff member sat down next to the resident. Staff were assisting another resident at the table and cuing Resident B to keep her awake and focused as she was eating with her bare hands. The clinical record for Resident B was reviewed on 03/26/24 at 11:01 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/03/24, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia and hypertension. The resident was totally dependent on staff members for bathing. The paper shower sheets for January, February, and March 2024, were provided by the DON (Director of Nursing) on 03/26/24 at 10:26 A.M. The records were dated and indicated the following: - On 01/01/24, the resident did not receive a shower, - On 01/07/24, the resident did not receive a shower, - On 01/21/24, the…

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

Based on observation, interview, and record review, the facility failed to follow physician's orders related to wound treatments and TED (anti-embolism) hose for 3 of 20 residents reviewed for quality of care. (Residents 44, 61, and 30) Findings include: 1. During an observation and interview on 03/20/24 at 1:33 P.M., Resident 44 was sitting on a couch in his room and indicated he had a sore on his toe. The clinical record for Resident 44 was reviewed on 03/21/24 at 2:38 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/21/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, anemia, hypertension, non-Alzheimer's dementia, depression and pain in his left foot. A Wound assessment, dated 02/19/24, indicated the resident had an arterial wound to the left foot. A physician's order, dated 12/24/23 through 01/22/24, indicated the staff were to apply betadine moist gauze and alginate, foam, and sterile gauze between the left great toe and second toe, and wrap with gauze, every day shift. A physician's order, dated 01/23/24…

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

Based on observation, interview, and record review, the facility failed to label and store medications appropriately for 2 of 3 medication storage refrigerators observed. (Station 1 medication refrigerator and Station 3 medication refrigerator) Findings include: Medication storage was observed on 03/26/24 at 1:41 P.M., with the ADON (Assistant Director of Nursing). 1. The medication refrigerator on Station 1 contained an open vial of TB (Tuberculin) serum with no label indicating when it was opened. The vial was about half full. The ADON could not recall when the last resident was admitted to the unit. 2. The medication refrigerator on Station 3 contained an open vial of TB serum with no label indicating when it was opened. The vial was one quarter full. The ADON could not recall when the last resident was admitted to the unit. LPN (Licensed Practical Nurse) 3, who was present at the time, indicated she had administered the serum to Resident 8 last week. During an interview on 03/26/24 at 2:10 P.M., the DON (Director of Nursing) indicated the TB serum vials should be dated when they…

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

Based on observation, record review, and interview, the facility failed to ensure residents' rights to a dignified existence related to toileting and dining for 5 of 7 residents reviewed for Activities of Daily Living. (Residents B, C, E, F, and G) Findings include: 1. During an observation on 8/22/23 at 10:50 a.m., CNA (Certified Nurse's Aide) 2 and CNA 3 entered Resident B's room to check and change him and get him up for lunch. Resident B was in bed, eyes closed, and covered with a blanket. The CNAs did not identify themselves to the resident. CNA 2 told him, Come this way, rolled him to the left, he grabbed the grab bar, then CNA 3 told him, Come this way and rolled him to the right. They checked him, he was clean and dry. They used the lift to transfer him to the wheelchair. Resident B never opened his eyes. The clinical record for Resident B was reviewed on 8/22/23 at 10:10 a.m. A Quarterly MDS (Minimum Data Set) assessment, dated 5/20/23, indicated the resident was severely cognitively impaired. The resident required two-person extensive assistance for toileting 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.