Bethel Manor

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 3 of 3 residents reviewed for transmission based precautions, and failed to position fans to prevent cross contamination in the laundry processing area for 1 of 2 random observations of the laundry room. (Resident 57, Resident 60, Resident 17, and Laundry Room) Findings include: 1. On 7/23/24 at 7:57 A.M., a PPE (personal protective equipment) cart was observed outside of Resident 57's room. There was no sign observed indicating instructions for specific use of the PPE or to see the nurse before entering the room. On 7/23/24 at 8:00 A.M., Resident 57's clinical record was reviewed. The clinical record lacked orders, care plans, and progress notes related to transmission based precautions. On 7/23/24 at 8:15 A.M., Licensed Practical Nurse (LPN) 23 indicated that Resident 57 was on EBP because he had a feeding tube. 2. On 7/23/24 at 8:15 A.M., LPN 23 indicated Resident 60 was on EBP because he had an indwelling urinary catheter. At that time, she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 2 of 2 residents observed with medications at bedside (Resident 49, Resident 23) Finding include: 1. On 7/21/24 at 10:16 A.M., Desitin was observed be to be on Resident 49's bedside table with Resident's name and physician noted on the label. On 7/21/24 11:10 A.M., Resident 49's clinical record reviewed. Diagnosis included, but not limited to, Alzheimer's disease with late onset. The MDS (Minimum Data Set) assessment dated [DATE] indicated that Resident 49 is severely cognitively impaired, required substantial/maximal assistance with toileting, substantial or maximal assistance with bathing, and substantial or maximal assistance with bed mobility. The clinical record lacked any self-administration of medication assessment or care plans. Physician orders included but were not limited to Desitin External Paste 40 % Zinc…

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 resident privacy for 2 of 2 random observations. Resident information was left visible on a computer screen during medication administration. (Resident 13, Resident 16) Finding includes: 1. On 7/24/24 at 10:00 A.M., Licensed Practical Nurse (LPN) 5 was observed gathering medications at a medication cart. When LPN 5 walked away from the medication cart and down the hall, the computer screen was left up with Resident 13's information visible (picture, name, date of birth , and medication list). LPN 5 came back to the cart at 10:04 A.M., and promptly left the cart again to enter a resident's room. At 10:06 A.M., Resident 3 was observed walking by the medication cart. LPN 5 returned to the cart at 10:06 A.M. 2. On 7/24/24 at 11:17 A.M., the medication cart was observed sitting between the nurses station and elevator with the computer screen open and Resident 16's information visible. LPN 5 was observed at that time in the Dining Room with a resident. At 11:19 A.M., Certified Nurse Aide (CNA) 3 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review the facility failed to protect the resident's rights to be free from physical abuse for 1 of 1 residents reviewed. Resident 36 was hit by CNA(Certified Nurse Aide) while receiving care resulting in laceration above the left eye. (Resident 36) Findings include: On 7/22/24 at 10:28 A.M., Resident 36 was observed in a chair smiling. On 7/22/24 at 1:21 P.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, ALZHEIMER'S DISEASE and Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. The current Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 36 was severely cognitively impaired. The resident was dependent on transfer, toileting, and dressing. Current physician orders included, but were not limited to: Lexapro Tablet 10 MG (Milligrams) (Escitalopram Oxalate)(Antidepressant medication). Give 1 tablet by mouth one time a day for depression/anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services upon admission for 1 of 3 residents reviewed for skin impairment. A resident who was admitted with skin impairment did not have treatment orders put in place upon admission. (Resident 101) Finding includes: On 9/4/24 at 11:09 A.M., Resident 101's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing, chronic kidney disease, stage 4, (severe), type 2 diabetes mellitus without complications. An admission MDS (Minimum Data Set) Assessment, dated 9/3/24, was still in progress and indicated Resident 101's cognition was moderately impaired. Care plans included, but were not limited to: Resident has actual impairment to skin integrity AEB (as evidenced by) diabetic ulcer to left 2nd toe and diabetic ulcer to left heel, and shearing to sacrum r/t (related to)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure person-centered care plans were developed and implemented for 2 of 5 residents reviewed for unnecessary medications and behaviors. (Resident 37, Resident 49) Finding includes: 1. On 7/23/24 at 1:59 P.M., Resident 37's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/4/24, indicated Resident 37 was severely cognitively impaired, required substantial assistance from staff for toileting and bathing, and was receiving antianxiety, antidepressant, diuretic, antiplatelet, and hypoglycemic medications. Current physician orders included, but were not limited to: Lexapro (antidepressant medication) 10 mg (milligram) Give 1 tablet by mouth at bedtime, start date 12/8/23. Ativan (antianxiety medication) 0.5 mg (Lorazepam) Give 1 tablet by mouth one time a day, start date 4/12/24. Lasix (diuretic medication) 20 mg Give 1 tablet by…

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 residents were free of any significant medication errors for 1 of 5 residents reviewed for unnecessary medications. A resident was given the wrong medication resulting in rebound congestion when the medication was discontinued. (Resident 56) Finding includes: On 7/23/24 at 9:23 A.M., Resident 56's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, depression, and psychotic disorder. The most recent admission MDS (Minimum Data Set) Assessment, dated 5/6/24, indicated no cognitive impairment and no behaviors. Resident 56 required supervision with bed mobility, eating, transfers, and toileting. Physician orders included, but were not limited to: Nasal spray nasal solution 0.05% (Oxymetazoline HCl) 2 sprays in both nostrils two times a day for allergies, dated 6/3/24 through 7/1/24. (medication if used more than 3 days may cause rebound congestion) Saline nasal solution 0.65% (Saline) 2 sprays in both nostrils four times a day for nasal congestion for 5 days, dated 7/3/24. A Nurse…

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 prevention of pressure ulcers for 2 of 3 residents reviewed for pressure injury. Interventions were not followed, and wound assessments were not completed as ordered. (Resident 54, Resident 55) Findings include: 1. On 7/21/24 at 12:42 P.M., Resident 54 was observed lying in bed on her back. When the resident was rolled to the left side, there was no dressing observed covering the pressure area on her sacrum. At that time, the area was observed slightly open in the middle revealing subcutaneous tissue, and the area surrounding the pressure injury was observed a dark pink color indicative of a deeper wound under the skin. No drainage was observed. Granulation tissue (healing connective tissue in the wound bed) was observed in the middle of the wound. At that time, Licensed Practical Nurse (LPN) 21 did not indicate anything about a missing dressing. On 7/22/24 at 1:24 P.M., Resident 54 was observed lying on her back with the head of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed for falls. Interventions were not updated following falls. (Resident 52, Resident 28, Resident 11 Findings include: 1. On 7/21/24 at 9:43 A.M., Resident 52 indicated she had fallen about a month ago when she lost her footing. At that time, Resident 52 was sitting in a recliner with her walker in front of her. On 7/23/24 at 11:42 A.M., Resident 52's clinical record was reviewed. Diagnosis included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/18/24, indicated no cognitive impairment, and no behaviors. Resident 52 required supervision assistance of one staff with transfers. Current physician orders included, but were not limited to: Up with walker and staff assist and non skid shoes, dated 1/4/24. A current risk 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 ensure oxygen equipment was properly labeled and oxygen services were provided according to physician order for 1 of 1 reviewed for respiratory care. (Resident 24) Findings include: On 7/21/21 9:14 A.M., Resident 24 was observed sitting in recliner with nasal cannula in nostrils. The tubing was connected to an oxygen concentrator with a date of 6/30/24 written on the side of the tubing. There was also no oxygen warning sign on the outside of the door. On 7/22/24 at 9:40 A.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease) and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The current Annual MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was mildly cognitively impaired. The resident needed partial assistance with toileting and dressing and was wearing O2 (Oxygen). Current physician orders included but were not limited to:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure proper interventions were in place for monitoring symptom, side effects, and behaviors of medications for 2 of 2 residents reviewed for dementia. (Resident 46, Resident 37) Findings include: 1. On 7/23/24 at 4:09 P.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to unspecified dementia, unspecified severity, mood disturbance and anxiety disorder. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 46 was significantly cognitively impaired. Resident 46 was dependent for bathing, dressing, and toileting. MDS indicated the resident has a diagnosis of No Alzheimer dementia. Current physician orders included but were not limited to: Seroquel Oral Tablet 25 MG (Milligrams) (Quetiapine Fumarate).Give 1 tablet by mouth at bedtime for dementia with mood disturbance related to unspecified dementia, unspecified severity, with mood disturbance dated 4/15/24. Xanax Oral Tablet 0.25…

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 routine medications were available and dispensed according to physician's orders for 1 of 6 residents reviewed for medication administration. (Resident 28) Finding includes: On 7/23/24 at 10:08 A.M., Resident 28's clinical record was reviewed. Diagnosis included, but was not limited to, hyperlipidemia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 5/8/24, indicated Resident 28 had severe cognitive impairment and required setup assistance of staff for eating. Current physician orders included, but was not limited to: Pravachol (a medication to treat high cholesterol) Tablet 80 MG (milligrams) - Give 1 tablet by mouth one time a day for hyperlipidemia, dated 7/17/22. The July 2024 MAR (Medication Administration Record) indicated resident did not receive the medication on 7/18, 7/19, and 7/22 because it was on order. The MAR indicated the resident received the medication on 7/20 and 7/21. On 7/23/24 at 10:18 A.M., the pharmacy indicated Resident 28's Pravachol was reordered early the morning of…

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

Based on record review and interview the facility failed to ensure a resident was free from unnecessary medications for 1 of 1 residents reviewed for hospice. A resident's as needed anti-anxiety medication was ordered for more than 14 days. (Resident 49) Finding includes: On 7/21/24 at 11:10 A.M., Resident 49's clinical record was reviewed. Diagnosis included, but was not limited to, Alzheimer's Disease with late onset and Anxiety Disorder . The MDS (Minimum Data Set) dated 7/6/24 indicated that Resident 49's cognition was severely impaired and was currently receiving hospice services. Current physician orders included but were not limited to lorazepam oral tablet 0.5 MG, 1 tablet by mouth every 4 hours as needed for anxiety and agitation related to Anxiety Disorder. The order was dated 6/28/24 with no end date. On 07/25/24 at 10:53 A.M. the DON (Director of Nursing) indicated that PRN antianxiety medications should have been evaluated every 14 days, also that it would have been expected for the end date to be 14 days when order was put in. A Use of Psychotropic Medication 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 ensure medications were administered according to physician's orders and professional standards for 2 of 26 opportunities, resulting in a medication administration error rate of 7.69%. (Resident 53 and Resident 23) Findings include: 1. On 7/23/24 at 11:35 A.M., Licensed Practical Nurse (LPN) 46 was observed preparing a Humalog Kwikpen for insulin administration for Resident 53. An AccuCheck (blood glucose test) indicated the resident had a blood sugar of 313. LPN 46 indicated the resident received sliding scale insulin and was to receive 3 units of insulin Lispro (a fast acting insulin) for a blood glucose reading of 313. LPN 46 set the insulin pen to 3 units. She cleaned the tip of the pen, attached the needle, and administered 3 units of insulin to Resident 53 in her lower left abdomen. LPN 46 did not prime the insulin pen before administration of the medication. 2. On 7/24/24 at 12:02 P.M., Licensed Practical Nurse (LPN) 7 was observed preparing a Humalog Kwikpen (Lispro Insulin) for insulin administration…

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

Based on interview and record review, the facility failed to obtain consent before administering influenza vaccines for 2 of 5 residents reviewed for immunizations. (Resident 37 and Resident 36) Findings include: 1. On 7/22/24 at 2:00 P.M., Resident 37's clinical record was reviewed. Resident 37 received the influenza vaccine on 10/20/23. The clinical record lacked a signed consent for the influenza vaccination received on 10/20/23. On 7/23/24 at 1:27 P.M., the Director of Nursing (DON) provided the most current influenza vaccination consent form signed by Resident 37 dated 4/26/21. 2. On 7/22/24 at 1:45 P.M., Resident 36's clinical record was reviewed. Resident 36 received the influenza vaccine on 10/11/23. The clinical record lacked a signed consent for the influenza vaccination received on 10/11/23. On 7/23/24 at 10:43 A.M., Licensed Practical Nurse (LPN) 5 indicated that it took too long to call every family for influenza vaccination consent every year so if they accepted it once, she did not call them again. At that time, she indicated the floor nurse gave the influenza vaccine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who required restorative nursing services received services for 7 of 8 residents reviewed. (Resident B, Resident C, Resident E, Resident F, Resident G, Resident H, Resident J) Findings include: 1. On 4/18/23 at 8:21 A.M., Resident B was observed sitting in a chair, rocking with her eyes closed, and the TV turned on. On 4/18/23 at 12:44 P.M., Resident B's clinical record was reviewed. The diagnoses included, but were not limited to, age-related osteoporosis and congenital (present form birth) blindness. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 1/17/23, indicated Resident B was moderately cognitively impaired and that AROM (active range of motion) restorative therapy was provided 4 of 7 days and walking restorative therapy was provided 2 of 7 days within the seven day look back period. Resident B required extensive assist of 1 staff for bed mobility, transfers, and toileting. Care plans included,…

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 ensure residents environment remained free from accident hazards for 2 of 4 residents reviewed for falls. New interventions were not implemented following falls. (Resident H, Resident 5) Findings include: 1. On 4/19/23 at 11:40 A.M., Resident H was observed wondering the unit in a wheel chair. On 4/18/23 at 2:41 P.M., Resident H's clinical record was reviewed. The diagnoses included, but were not limited to, unspecified dementia and displaced midcervical fracture of left femur. The Quarterly MDS (Minimum Data Set) assessment, dated 3/23/23, indicated Resident H had severe cognitive impairment and required extensive assistance for transferring and dressing. Resident H was a high risk for falls. Resident H's physician orders included, but were not limited to, alarming floor mat, check placement, and functioning every shift, antirollback to wheelchair two times a day for fall reduction measure, and place resident's bed against the wall per family request. Resident H's care plan dated 6/22/22 included, but not limited to:…

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

Based on observation, interview, and record review, the facility failed to ensure services of a RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 2 of 7 days reviewed for nurse staffing. Findings include: On 4/19/23 at 10:30 A.M., the daily nursing assignment sheets were provided for the week of 4/3/23 through 4/10/23 and reviewed. The sheets indicated there was no RN coverage for Saturday, 4/8/23 and Sunday, 4/9/23. During an interview on 4/21/23 at 4:45 P.M., the Administrator indicated there was not RN coverage for those dates and there should have been 8 hours of consecutive RN coverage every day. On 4/21/23 at 4:45 P.M., a current undated Nursing Services and Sufficient Staff policy, was provided by the Administrator and indicated . the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 3.1-17(b)(3)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 1 residents reviewed for hospice. A resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 46) Finding includes: On 4/18/23 at 12:51 P.M., Resident 46's clinical record was reviewed. The diagnosis included, but was not limited to, anxiety. The Significant Change MDS (Minimum Data Set) Assessment, dated 3/21/23, indicated Resident 46's cognition was severely impaired and was currently on hospice. Current physician orders included, but were not limited to: Lorazepam Intensol Oral Concentrate (anti-anxiety medication) 2 MG (milligram)/ML (milliliter). Give 0.25 ml by mouth every 6 hours as needed for anxiety; restlessness related to anxiety disorder, dated 3/13/23. Resident 46's clinical record lacked any physician reassessment for lorazepam after the initial 14 days after it was ordered. The clinical record lacked a care plan addressing the anti-anxiety medication. During an interview on 4/20/23 at 1:23 P.M., the DON…

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 deteriorated medications carts were disposed of for 2 of 4 medication carts. Loose pills were found in the bottom of the medication cart drawers. (North Hall, South Hall) Findings include: 1. On 4/19/23 at 7:58 A.M., the medication cart on the North Hall was observed to have the following medications laying loose in the bottom of 2 drawers: 1 large white pill #12 1 small round pill with R # 25 1 small round blue pill with no writing 1 small round pill with # 1484 1 oblong peach pill with # 722 1 small round peach pill with PH # 034 1 small round white pill with #10 1/2 yellow pill could not read number 1 large round white pill with PH #020 1 small round white pill with no writing 1 white capsule with SG #179 1 peach round small pill with #OH 034 1 scored small white pill with # AC 152 1/2 small white pill with #49 1 small round clear orange 1 small oblong white pill with no number 1 large oblong pill with K #46 1 large round white pill with no number 1 small red round pill with PH # 32 1 small round red…

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.