Waters Of Rushville Skilled Nursing Facility, The

Based on observation, interview, and record review, the facility failed to ensure safety precautions were adhered to by failure to keep a medication cart locked and unsupervised during 1 of 3 medication administration observations with 1 of 3 staff and failed to ensure labeling of three insulin syringes, located in the west hall medication cart, included the dates each were opened or the date to dispose of the insulin during an observation of the medication carts for of 2 of 4 medication carts observed. (Resident 18, Qualified Medication Aide 2, and Registered Nurse 3) Findings include: 1. During a medication administration observation on 6-23-25 at 7:42 p.m., with Qualified Medication Aide (QMA) 2, the lighter colored medication cart on the east hall was observed to be unlocked, upon return to the medication cart after provision of medication to a resident. The cart was located in the hall, directly in front of the nurse's station and accessible to anyone passing by the medication cart. Upon bringing this to the attention of QMA 2 at that time, he indicated, My bad. I guess I…

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.

2. On 6-23-25 at 7:46 p.m., during a medication administration observation, QMA 2 was observed to prepare five (5) oral medications for Resident 99. Those medications and their physician instructions included the following: - atorvastatin 40 milligrams (mg) at bedtime for elevated blood fats. - tab-a-vite one tablet once daily for unspecified vitamin deficiency. - hydroxyurea 500 mg twice daily on Monday, Wednesday and Friday and once daily on Tuesday, Thursday, Saturday and Sunday for gout: wear gloves when handling or crushing; do not crush. - furosemide 40 mg twice daily for congestive heart failure. - metoprolol succinate extended-release 50 mg twice daily for high blood pressure. QMA 2 was observed to touch each medication with his bare hands during the preparation of the medications. When queried about touching the hydroxyurea with his bare hands and the labeled instructions, he responded, I guess I didn't see that. When queried regarding touching each pill with bare hands, he indicated that he should not have done that and would now need to replace the medications. On 6-27-25…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who was admitted to the facility with a pressure ulcer received thorough assessment upon admission, initiated a treatment timely for an identified pressure ulcer, and initiated treatment changes per the wound provider promptly for 1 of 3 residents reviewed for pressure ulcers. (Resident C) This deficient practice was corrected on 2/14/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding pressure ulcers, reviewed all wound reports from the wound care provider for January and February of 2025 to identity potential residents, and conducted a review of residents with pressure ulcers to ensure assessments have been completed and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: 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 ensure 3 of 3 residents reviewed for falls had a minimum of 72 hours post-fall assessments, including neurological (neuro) checks as appropriate. (Residents B, F and G) Findings include: 1. The clinical record of Resident B was reviewed on 2-19-25 at 2:56 p.m. His diagnoses included, but were not limited to, alcohol dependency with unspecified withdrawal, weakness, difficulty in walking and repeated falls. An admission note, dated 1-23-25 at 10:43 p.m., indicated he was weak and unsteady with his balance and gait. A fall risk assessment, dated 1-23-25, indicated he was at high risk for falls. His admission Minimum Data Set (MDS) assessment, dated 1-27-25, indicated he was moderately cognitively impaired, and he had sustained falls in the one month and two to six month time periods prior to admission. Resident B's care plans addressed both cognitive impairments and being at risk for falls. A nursing progress note, dated 1-28-25 at 5:45 a.m., indicated Resident B sustained an unwitnessed fall and was found lying on the floor…

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 ensure residents who admitted to the facility had their orders transcribed correctly into the electronic health record (EHR) that resulted in medication errors for 1 of 3 residents reviewed for medication administration. (Resident D) This deficient practice was corrected on 2/12/25, prior to the start of the survey, and was therefore past noncompliance. The facility implemented a systemic plan that included the following actions: in-service education to nursing staff related to the policy and procedure regarding transcribing physician orders and the admission process, reviewed all newly admitted residents to identity potential residents, and ongoing review of newly admitted residents during the morning clinical meetings have been completed and documented with ongoing review presented to the Quality Assessment and Assurance (QAA) Committee for review. Findings include: The clinical record for Resident D was reviewed on 2/20/25 at 2:10 p.m. The diagnoses…

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 eight hours of consecutive RN coverage for 9 of 91 days reviewed. This deficient practice had the potential to affect 34 residents. Findings include: The PBJ (Payroll Based Journal) Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2024 (October 1 - December 31) reviewed on 3/25/2024 at 1:45 p.m. indicated that nine days were noted without eight hours of consecutive RN coverage. An interview on 3/26/24 at 1:34 p.m. with Corporate Payroll indicated that he did not report any RN coverage for those aforementioned nine days due to no RN being on the skilled nursing facility. An interview with Regional Nurse Consultant on 3/27/2024 at 1:20 p.m. indicated that the facility was unable to find RN coverage for that time. During that time, they were utilizing their own staff and agency, but could not fill RN coverage consistently. An interview with Regional Nurse Consultant on 3/27/2024 at 2:20 p.m. indicated they did not have a specific policy for RN coverage, but the facility would follow the Center 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.

Based on interview and record review, the facility failed to accurately code Section J regarding falls for 2 of 17 residents reviewed for Minimum Data Set accuracy. (Resident 14 and Resident 16) Findings include: 1. The clinical record for Resident 14 was reviewed on 3/25/2024 at 2:45 p.m. The medical diagnosis included dementia. An Annual Minimum Data Set (MDS) Assessment, dated 1/27/2024, indicated Resident 14 had one fall without injury during that review period. A nursing progress note, dated 1/13/2024, indicated that Resident 14 was found lying on her right side on her floor mat with a bruise to the right elbow. 2. The clinical record for Resident 16 was reviewed on 3/25/2024 at 2:10 p.m. The medical diagnosis included dementia. An Annual MDS Assessment, dated 9/26/2023, indicated that Resident 16 had one fall without injury during that review period. An intradisciplinary note for Resident 14, dated 8/23/2023, indicated she had a fall that resulted in head laceration requiring staples for closure. An intradisciplinary note for Resident 14, dated 9/13/2023, indicated she 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 observations, interview, and record review, the facility failed to accurately monitor residents for bruising per physician order for 2 of 3 residents reviewed for bruising. Findings include: 1. The clinical record for Resident 14 was reviewed on 3/25/2024 at 2:45 p.m. The medical diagnosis included dementia. An Annual Minimum Data Set (MDS) Assessment, dated 1/27/2024, indicated Resident 14 was cognitively impaired and at risk for developing skin impairments, but did not have any alternations in skin. A bruising care plan, dated 2/6/2020, indicated to monitor skin daily during care. A physician order for Resident 14, dated 12/14/2022, indicated to monitor three times a day for chronic bruising to her bilateral arms. A physician's order for Resident, dated 1/24/2022, indicated for Resident 14 to utilize aspirin 81 milligrams (mg) every day. An observation on 3/25/2024 at 11:37 a.m. indicated she was sitting in the common area in her wheelchair. She was noted to have long sleeves that were slightly pulled up. A moderate sized bruise with a scabbed area was noted to her left…

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

Based on observation, interview, and record review the facility failed to implement a pressure relieving intervention as ordered by the podiatrist for a resident with an unstageable pressure ulcer (full thickness tissue loss ulcer covered by eschar) on the right heel for 1 of 2 residents reviewed for pressure ulcers (Resident 4). Finding include: During an observation and interview with Resident 4 on 3/25/24 at 1:06 p.m., indicated she had a pressure ulcer on her right heel, the physician told her on 3/21/24 when she seen him in his office. The resident indicated the physician told her to keep it off the ground. The resident was observed to be sitting in her wheelchair with her right heel directly on the floor. During an observation on 3/26/24 at 11:05 a.m., Resident 4 was sitting in the dining room with her right heel on floor. During an observation and interview on 3/26/24 at 12:28 p.m., Resident 4 sitting in her room in wheelchair with her right heel on the floor, she indicated she had worn an off-loading boot before, but had not been offered one with this pressure ulcer on her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based in interview, observation, and record review, the facility failed to ensure a left-hand protector or brace was available for 1 of 1 resident reviewed for contractures. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 3/26/2024 at 2:05 p.m. The medical diagnosis included heart failure. An Annual Minimum Data Set Assessment indicated Resident 10 had moderate cognitive impairment. An interview and observation with Resident 10 on 3/25/2024 at 1:22 p.m. indicated that her left hand does hurt sometimes and her contracture to the left hand has worsened. She stated they used to use padding to her left palm about a year ago, but the staff gave up on using it after it was lost. She was open to trying to utilize something to her left hand for her contractures. She stated there is nothing in her room they used for her hand, and nothing was visible on the surfaces like a hand brace or palm protector. An interview and observation with Resident 2 on 3/26/2024 at 1:00 p.m. indicated that…

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 ensure the fall mat was in place for a resident while in bed for 1 of 3 residents reviewed for falls. (Resident 7) Findings include: The clinical record for Resident 7 was reviewed on 3/26/2024 at 11:00 a.m. The medical diagnosis included dementia. A Quarterly Minimum Data Set Assessment, dated 2/15/2024, indicated that Resident 7 was cognitively impaired. A nursing assessment, dated 3/22/2024, indicated that Resident 7 was at high risk for falls. A physician order, dated 1/3/2023, indicated for Resident 7 to .have a mat on the floor by her bed, while she is in it An observation on 3/25/2024 at 11:46 a.m., indicated Resident 7 was laying in her bed at this time with her fall mat folded in three and stored between the foot of her bed and closet. An observation on 3/25/2024 at 1:20 p.m., indicated Resident 7 was laying in her bed at this time with her fall mat folded in three and stored between the foot of her bed and closet. She had a bottled drink in her hand at this time. An observation and interview with…

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 timely enter a resident with a significant weight loss into the Skin and Weight Assessment Team (SWAT) program for 1 of 3 residents reviewed for significant weight loss. Findings include: The clinical record for Resident 14 was reviewed on 3/25/2024 at 2:45 p.m. The medical diagnosis included abnormal weight loss. Weights for Resident 14 were record as: 2/1/2024 - 99.8 lbs. (pounds) 3/1/2024 - 94.3 lbs. (-5.51% from 2/1/2024) 3/2/2024 - 92.1 lbs. (-7.72% from 2/1/2024) A SWAT note, dated 3/21/2024, indicated new interventions of including a power pudding to the lunch tray for Resident 14. An interview with the Regional Nurse Consultant on 3/27/2024 at 1:20 p.m. indicated that no SWAT notes were found for Resident 14 between 3/1/2024 and 3/21/2024. A policy entitled, SWAT PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM) was provided by the Regional Nurse Consultant on 3/26/2024 at 10:55 a.m. The policy indicated, .It is the policy of this facility to assess the nutritional status of each resident .These residents will be monitored…

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 timely inform Resident 14's provider of a significant weight change for 1 of 3 residents reviewed for nutritional needs. Findings include: The clinical record for Resident 14 was reviewed on 3/25/2024 at 2:45 p.m. The medical diagnosis included abnormal weight loss. Weights for Resident 14 were record as: 2/1/2024 - 99.8 lbs. (pounds) 3/1/2024 - 94.3 lbs. (-5.51% from 2/1/2024) 3/2/2024 - 92.1 lbs. (-7.72% from 2/1/2024) An intradisciplinary note from 3/21/2024, that addressed Resident 14's weight loss, did not indicate the physicians was notified of the weight loss. An interview with the Regional Nurse Consultant on 3/27/2024 at 1:20 p.m. indicated she could not locate in the medical record where the attending physician was notified of the significant weight loss for Resident 14.

Based in interview and record review, the facility failed to ensure that a pharmacy recommendation was completed in a timely manner for 1 of 5 residents reviewed for pharmacy services. (Resident 2) Findings include: The clinical record for Resident 2 was reviewed on 3/26/2024 at 2:05 p.m. The medical diagnosis included heart failure. An Annual Minimum Data Set Assessment indicated Resident 10 had moderate cognitive impairment. A pharmacy recommendation, printed on 10/15/2023, contained a recommendation regarding a gradual dose reduction of Resident 2's antidepressant. This recommendation was not signed by a practitioner until 12/14/2023 agreeing with the reduction in her antidepressant. A correlating physician order to reflect the reduction in Resident 2's antidepressant was entered in the medical record on 12/19/2023. An interview with the Regional Nurse Consultant on 3/27/2024 at 2:20 p.m. indicated she had no further information to provide regarding the pharmacy recommendation. A policy entitled, Policy and Procedure-Pharmacy Recommendations, was provided by the Regional 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.

Based on interview and record review, the facility failed to ensure a prescription narcotic was not administered to a resident without an appropriate prescription for the narcotic for 1 of 6 residents reviewed for correct receipt of medications. (Resident C) Findings include: In an interview on 3-19-24 at 9:27 a.m., with a family member of Resident C, she indicated she remained upset that it took over 14 hours before family was notified of the medication error. They told me the nurse did not tell them and they did not find the error until the next day and that I was notified as soon as they were made aware of the error. A progress note for Resident C, dated 2-26-24 at 2:40 p.m. indicated, NP [nurse practitioner] approached AODN [Assistant Director of Nursing] this shift, res [resident] has stated to NP that she had received 2 Tramadol at HS [bedtime] on 2-25-24, ADON [Assistant Director of Nursing] confirmed that res did received [sic] medications, vs [vital signs] obtained, POA [power of attorney], admin [administrator], DON [Director of Nursing], notified, will cont [continue] 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 their medication administration error rate remained under five (5) percent during 3 observations with 4 staff and 11 residents. (Residents E,and G) Findings include: 1. During a medication pass observation on 3-18-24 at 4:50 p.m., with Resident E, RN 4 was observed to administer one tablet of omeprazole 20 milligrams (mg). Upon reconciliation of Resident E's physician orders, the order indicated to administer omeprazole 20 mg in the evening at 3:00 p.m. This indicated the medication was given outside of the accepted practice of medications being administered within one hour before or after their scheduled time. In an interview with RN 5 on 3-19-24 at 8:40 a.m., she indicated it was facility policy to administer medications within a one hour window of the scheduled medication administration time. 2. During a medication pass observation on 3-18-24 at 4:59 p.m. with Resident G, RN 4 was observed to administer 4 units of Humalog insulin via a Humalog Kwikpen device subcutaneously into the right deltoid. RN…

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 infection control measures of handwashing and hand-hygiene were utilized during a medication pass administration observation conducted during 3 observations with 4 staff and 11 residents. (Residents E, F and G, ) Findings include: During a medication pass observation on 3-18-24 between 4:50 p.m. and 5:00 p.m., RN 4 indicated she wears gloves for medication passes. Upon completion of medication administrations to Residents E, F and G, RN 4 was observed to remove and discard her gloves, then obtain a single alcohol pad and wipe the palm of each of her hands with the alcohol pad. When queried about this practice, RN 4 responded she did not have any alcohol hand-sanitizer on her medication cart and the large container of alcohol hand-sanitizer was located on the desk at the nurse's station. In an interview on 3-19-24 at 12:35 p.m., with the Administrator, the Administrator was informed of concerns related to handwashing and hand-hygiene practices during a medication pass observation on 3-18-24, with RN 4.…

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 develop care plans related to the use of a wanderguard (safety device used as an audible alarm to notify staff of an exit or elopement attempt from a secured area) for 2 of 3 residents reviewed for the use of wanderguards. (Resident B and E) Findings include: 1. The clinical record of Resident B was reviewed on 10-30-23 at at 2:55 p.m. His diagnoses included, but were not limited to a history of traumatic brain injury (TBI), unspecified encephalopathy, viral hepatitis, falls and mild neurocognitive disorder. His most recent Minimum Data Set (MDS) assessment, dated 8-29-23, indicated he has moderate cognitive impairment, is ambulatory without use of an assistive device and did not indicate any wandering behaviors during the look-back period of the assessment. A review of Resident B's assessments for wandering and elopement reflected his admission assessment on 7-3-23 for wandering was a moderate risk, but he was not an elopement risk. Wandering risk assessments on 7-6-23 and 8-5-23 were unchanged. However, 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 ensure adequate supervision, related to the use of a wanderguard (safety device used as an audible alarm to notify staff of an exit or elopement attempt from a secured area), for 2 of 3 residents reviewed for the use of wanderguards. (Resident B and E) Findings include: 1. The clinical record of Resident B was reviewed on 10-30-23 at at 2:55 p.m. His diagnoses included, but were not limited to a history of traumatic brain injury (TBI), unspecified encephalopathy, viral hepatitis, falls and mild neurocognitive disorder. His most recent Minimum Data Set (MDS) assessment, dated 8-29-23, indicated he has moderate cognitive impairment, is ambulatory without use of an assistive device and did not indicate any wandering behaviors during the look-back period of the assessment. A review of Resident B's assessments for wandering and elopement reflected his admission assessment on 7-3-23 for wandering was a moderate risk, but he was not an elopement risk. Wandering risk assessments on 7-6-23 and 8-5-23 were unchanged.…

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 complete a significant change of condition assessment within 14 days of change of condition for a resident electing hospice service for 1 of 2 residents reviewed for significant change of condition. (Resident 37) Findings include: The clinical record for Resident 37 was reviewed on 12/15/2022 at 02:50 p.m. The medical diagnoses included, but were not limited to, heart failure and malignant neoplasm of the prostate. A physician order, dated 12/13/2022, indicated to admit to hospice effective 10/4/2022 for diagnoses of health failure with a life expectancy of 6 months of less if the terminal illness runs its normal course. No Significant Change Minimum Data Set Assessment was completed in October 2022. An interview with Minimum Set Assessment Corporate Support on 12/15/2022 at 3:10 p.m. indicated that a Significant Change MDS Assessment should be completed within 14 days of election of hospice services. It was identified that Resident 37 did not have a SCSA completed and one was scheduled for 12/14/2022. The Center 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.

Based on record review and interview the facility failed to accurately indicate weight gain/loss for Resident 28, dehydration for Resident 29 and failed to indicated hospice services and prognosis of 6 months or less for Resident 37 for 3 of 6 residents for accuracy of Minimum Data Set (MDS) Assessments. Findings include: 1. The clinical record for Resident 28 was reviewed on 12/15/22 02:56 p.m. The medical diagnoses included, but were not limited to, intracerebral hemorrhage and diabetes mellitus. The following weights were recorded for Resident 28: 1/5/2022 145.9 lbs. (pounds) 2/23/2022 136.4 lbs. 3/2/2022 134.4 lbs. 3/16/2022 134.6 lbs. 4/13/2022 129.7 lbs. 4/20/2022 130.0 lbs. 5/3/2022 137.8 lbs. 5/23/2022 133.9 lbs. 6/1/2022 133.1 lbs. 6/6/2022 133.2 lbs. 6/15/2022 135.8 lbs. 7/6/2022 139.8 lbs. 8/3/2022 136.1 lbs. 9/7/2022 137.7 lbs. 10/5/2022 139.8 lbs. 11/11/2022 139.1 lbs. 11/30/2022 145.5 lbs. 12/12/2022 143.9 lbs. A Quarterly MDS Assessment, dated 11/10/2022 indicated Resident 28 had a weight gain and a weight loss. 2. The clinical record for Resident 29 was reviewed 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.