Chase County Care And Rehab

The resident reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment in the kitchen for residents and staff. Findings included: - During the initial tour of the kitchen on 01/30/24 at 03:15 PM, the following area of concern was noted: The floor throughout the kitchen had areas which contained a build-up of dirt. The parameter of the floor had a heavy build-up of dirt and grime. The floor where table legs stood had a build-up of grime. On 02/01/24 at 10:09 AM, Dietary Staff BB, confirmed the kitchen floor needed to be kept clean at all times. The facility policy for Sanitation, effective 10/2023, included: Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. The facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable and homelike environment on one of three resident hallways of the facility. Findings included: - During an environmental tour on 02/01/24 at 10:27 AM with Consultant Staff GG, the following areas of concern were noted: 1. One resident room had a hole through the sheetrock wall which measured approximately 11 by two inches. The floor of the room had a build-up of visible dirt and grime around the parameter of the room. The shelf in the bathroom over the sink had worn, missing paint and the sink of the bathroom had a large blackened area on the front where the porcelain had worn away. 2. One resident room had broken wood and missing, chipped paint on one closet door. The TV stand had various areas of chipped, missing paint. A seat riser over the bathroom toilet had a large amount of a dried, brownish substance. 3. One wall in a resident room had an area of missing paint approximately eight by three inches, above the TV. The tile…

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 The facility reported a census of 32 residents with 15 selected for review which included three residents reviewed for transfer to hospital. Based on interview and record review, the facility failed to issue a Bed Hold (a document that indicates a resident's desire to keep their bed available and indicates financial implications if any apply) as required for one Resident (R)13 of the three residents reviewed for transfer to a hospital. Findings included: - Review of Resident (R)13's Physician Order Sheet dated 01/05/24, revealed diagnoses that included myasthenia gravis (abnormal condition that caused muscles to tire and weaken easily). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The ADL (Activity of Daily Living) Functional/Rehabilitation Care Area Assessment (CAA), dated 12/27/23, assessed the resident experienced an exacerbation of myasthenia gravis, and upon return 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 The facility reported a census of 32 residents with 15 residents sampled. Based on interview and record review, the facility failed to accurately complete a Minimum Data Sets (MDS) for two Residents (R)3, regarding documentation for falls and R 33, regarding discharge. Findings included: - Review of Resident (R)33's electronic medical record (EMR) revealed a diagnosis of a spinal injury (physical damage to the spinal cord which interfere with normal motor, sensory or autonomic function). The admission Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility from an acute hospital. The Discharge MDS, dated 12/08/23, documented the resident discharged to an acute hospital and his return was not anticipated. Review of the resident's EMR revealed the resident had received a physician's order 12/01/23 to discharge to home with home health. Review of the resident's EMR revealed a Discharge Assessment, dated 12/06/23, which documented the resident was to discharge home. On 02/01/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 32 residents with 15 residents included in the sample. Based on observation, record review and interview, the facility failed to review and revise the care plans for one sampled Resident (R)3, regarding fall interventions. Findings included: - Review of Resident (R)3's electronic medical record (EMR) revealed the following diagnoses: Schizoaffective disorder (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. He had inattentive behavior continuously and impairment in range of motion (ROM) on one side of his lower extremity. He had two or more non-injury falls since his prior assessment (this section of the MDS was inaccurate) and required substantial to maximal staff assistance for transfers…

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 The facility reported a census of 32 residents with 15 selected for review. Based on observation, interview and record review, the facility failed to ensure one sampled Resident (R)137 received appropriate treatment to bilateral (both sides) lower extremity cellulitis (skin infection caused by bacteria) and received proper ear care. Findings included: - Review of Resident (R)137's medical record revealed diagnosis that included Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), narcolepsy (a chronic neurological disorder that affects the ability to control sleep-wake cycles), and encephalopathy (broad term for any brain disease that alters brain function or structure). The Annual Minimum Data Set (MDS), dated [DATE], assessed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 32 residents with 15 residents sampled, including five residents reviewed for accidents. Based ON observation, interview, and record review, the facility failed to initiate an appropriate intervention following one non-injury fall for Resident (R)3, to prevent further falls. Findings included: - Review of Resident (R)3's electronic medical record (EMR) revealed the following diagnoses: Schizoaffective disorder (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating severe cognitive impairment. He had inattentive behavior continuously and impairment in range of motion (ROM) on one side of his lower extremity. He had two or more non-injury falls since his prior assessment (this section of the MDS was inaccurate) and required…

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 The facility reported a census of 32 residents with 15 selected for review, which included six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure timely follow-up of the pharmacist's recommendations for two of the six sampled Residents (R)7 and R3. Findings included: - Review of Resident (R)7's Physician Order Sheet dated 11/13/23, revealed diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), hypothyroidism (condition characterized by decreased activity of the thyroid gland) and hyperlipidemia (condition of elevated blood lipid levels). The Care Plan reviewed 11/30/23, instructed staff to review the pharmacy consultant recommendations and to follow-up as indicated. On 08/02/23, the physician instructed staff to administer Depakote (an antiseizure medication with mood altering…

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 The facility reported a census of 32 residents with a sample of 15 residents, including six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to prevent two residents from unnecessary medications, including Resident (R)19, regarding giving medication outside of parameters and R 7, regarding the pharmacy consultant's recommendation to acquire labs. Findings included: - Review of the electronic medical record (EMR) for Resident (R)19, revealed a diagnosis of orthostatic hypotension (blood pressure dropping with change of position). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a diagnosis of orthostatic hypotension (decrease in blood pressure (BP) with movement). The Quarterly MDS, dated 09/23/23, documented the resident had a diagnosis of hypertension (HTN- high blood pressure). The care plan, dated 10/11/23, lacked staff instruction regarding the resident's orthostatic hypotension. Review of the resident's EMR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 30 residents with eight residents selected for review and one resident reviewed for neglect. Based on observation, interview, and record review, the facility neglected Resident (R)1 when they left him unattended at a clinic during an out of town appointment on 08/29/23. R1 exited the clinic with clinic staff then left the premises around 04:00 PM to 04:30 PM. R1 was later found by facility staff 1.8 miles away from the clinic on 08/29/23 at 06:19 PM. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), acquired absence of right and left leg above knee, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), history of traumatic brain injury, stimulant use, mild neurocognitive disorder, and need for assistance with personal care. The admission Minimum Data…

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.

The facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure to clean the nebulizer kit (device which changes liquid medication into a mist easily inhaled into the lungs) for Resident (R)3 and R4 after use. These practices increased the risk of R3 and R4 for developing a respiratory infection. Findings included: - On 09/06/23 at 09:24 AM, Licensed Nurse (LN) G entered R3's room to administer his nebulizer treatment. The nebulizer kit was connected and rested directly on top of the nebulizer machine. LN G placed the medication in the nebulizer kit medication cup and handed the kit to the resident. On 09/06/23 at 09:33 AM, LN G entered R4's room to administer his nebulizer treatment. The nebulizer kit mask was hanging off the overbed table approximately a foot above the floor and dated 09/04. An additional nebulizer kit was connected and stored in a bag on the wall with a date of 09/03. While trying to get a hold of the mask hanging off the overbed table, 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.

The facility reported a census of 30 residents with eight selected for review including five reviewed for Influenza and Pneumococcal Immunizations. Based on record review and interview, the facility failed to obtain immunization status for Resident (R)1 and failed to provide additional immunization to R5. Findings included: - The Minimum Data Set tab for R1 revealed he entered the facility on 05/11/23. The Immunization tab lacked information of R1 receiving the Pneumococcal vaccine. The Miscellaneous tab lacked a consent/declination for the Pneumococcal vaccine for R1. The Resident Vaccination binder lacked a consent/declination for the Pneumococcal vaccine for R1. On 09/06/23 at 01:10 PM, Administrative Nurse E stated the status of the Pneumococcal vaccine should have been addressed on admission. The facility policy Pneumococcal Vaccine dated October 2022 revealed residents will be offered the Pneumococcal vaccine to aid in preventing Pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine, and when…

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.

The facility reported a census of 25 residents. Based on observation, interview, and record review, the facility failed to store drugs and biologicals in a locked compartment. Findings included: - On 5/25/22 at 01:00 PM, the medication cart observed unlocked. The Licensed Nurse and the Certified Medication Aide were no where available. The surveyor notified nurse consultant staff HH, in an adjoining office, who then went out of the office and to the medication cart and confirmed the medication cart unlocked. She reported staff should always keep the medication cart locked when the staff were not available. The facility policy Administering Medications, dated 05/2021, revealed during administration of medications, the medication cart was to be kept closed and locked when out of sight of the medication nurse or aide. The facility failed to appropriately store drugs and biologicals in a locked compartment by not locking the medication cart.

The facility reported a census of 25 residents. Based on observation, interview, and record review the facility failed to provide sanitary food preparation and storage for the residents of the facility. Findings included: - Tour of the kitchen, on 05/22/22 at 09:59 AM, with Dietary Staff BB revealed the following concerns: 1. The refrigerator contained two undated glasses of fruit punch, one undated opened carton of chocolate milk, and one undated glass of Kool-aide. 2. The freezer contained three undated serving bowls of scooped ice cream. 3. The hood over the stove had peeling paint inside the right front corner. On 05/22/22 at 09:59 AM, Dietary Staff BB, confirmed the above findings and agreed that the glasses of punch, Kool aide, and the open carton of chocolate milk. Staff should have labeled the items with the date it was opened, used, and stored in the refrigerator. Additionally, she confirmed the stove hood needed to be repaired to prevent food borne illnesses. The facility policy Food Safety-Storage, dated 04/2021, documentation included food would be stored and protected…

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.

The facility reported a census of 25 residents. Based on observation, interview, and record review the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for resident and staff in the laundry. Findings included: - On 05/24/22 at 03:24 PM, the laundry tour with Administrative Staff A, and Maintenance Staff U, revealed the following environmental concerns: 1. An unsanitizable bare wood riser/pallet under the laundry chemicals sat directly on the floor. 2. A three-foot section of base board missing in the laundry folding room that extended into the laundry processing room. 3. An approximate two-foot section of the wall, that extended from the dryer, had peeled/chipped paint. 4. The laundry folding room had six broken and cracked floor tiles. 5. The laundry folding counter tops had peeled laminate. 6. A ceiling in the folding laundry area with approximately a three foot round brown stain with a hole approximately two feet round open area. 7. In addition, a second hole in the ceiling that measured approximately four feet by five…

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.

The facility reported a census of 25 residents. Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in the room designated as the beauty shop. Findings included: - An observation on 05/24/22 at 03:34 PM revealed these findings: 1. A build-up of dust covered a black wheeled cart located between the two chairs with dryers, the sink pipes, and on the hair style products stored under the hinged countertop which covered the sink. 2. Both hair dryer vents covered with lint build-up. 3. The ceiling had a crack across the middle of the ceiling that measured approximately to the width of the ceiling. 4. The beauty shop chair contained opened cracks in the material at the top and the back of the backrest and rust was present to the base of the chair. 5. The cushion in the seat of the hair dryer chair contained hair and dust. 6. Both hair dryers had a layer of dust. 7. An undated bleach bottle stored directly on the floor. The bleach bottle had hair and a build-up 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.

The facility reported a census of 25 residents. Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent. Observation of 29 physician ordered medications revealed four medications in error, resulting in a medication error rate of 13.79%. These errors affected Resident (R)28, R23, and R130. Findings included: - The electronic medical record (EMR) for Resident (R)28, included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Treatment Administration Record (TAR) dated 05/2022 for R28 included an order, with a start date of 04/13/22, for Humalog insulin, 10 units, subcutaneously (under the skin), three times a day. If R28 would eat half of the meal, staff may administer six units. If the resident skipped the meal, may hold the insulin dose for that meal. The third dose of the day scheduled at 04:00 PM. On 05/23/22 at 04:27 PM R28 was in his room sitting up in his wheelchair. On 05/23/22 at 04:28 PM Licensed Nurse (LN) G…

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 The facility reported a census of 25 residents with 14 sampled, which included two residents reviewed for choices. Based on observation, interview, and record review, the facility failed to provide choices for dependent Resident (R)7 related to his preferences for frequency of bath/shower. Findings included: - Review of the Resident (R)7's, Physician Orders, dated 05/18/22, revealed diagnoses which included after care following surgical bilateral (both sides) below the knee amputations, embolism (blood clot) of right lower extremity, and generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The admission Minimum Data Set (MDS) dated [DATE], documented the resident with highly impaired vision. His Brief Interview for Mental Status (BIMS) score of 13, which indicated cognitively intact. He reported it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath. The resident required supervision of staff for bed mobility. He…

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 The facility reported a census of 25 residents which included 14 residents sampled for review. Based on observation, interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS) for one selected Resident (R)22 after the resident experienced a change of condition in at least two or more activities of daily living (ADLs) with a significant change in the resident's physical or mental condition, that had an impact on more than one area of the resident's health status Findings included: - Review of Resident's (R)22's, Physician Orders, dated 04/09/22, revealed diagnoses which included, legal blindness, major depressive disorder (major mood disorder), morbid obesity (severely overweight), lumbago (lower back pain), with sciatica (pain affecting the back hip, and outside of the leg, caused by compression of a spinal nerve root in the lower back) of the right side, chronic peripheral venous insufficiency (improper functioning of the vein valves in the leg, causing swelling…

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 The facility reported a census of 25 residents which included 14 residents sampled for review which included one Resident (R)22 reviewed for Increase/Prevent Decrease in Mobility. Based on observation, interview, and record review, the facility failed to ensure resident (R)22 received needed treatment/care to maintain Range of Motion (ROM) an/or Mobility and/or to prevent further decline in ROM/Mobility. Findings included: - Review of Resident's (R)22's Physician Orders, dated 04/09/22, revealed diagnoses which included legal blindness, major depressive disorder ( abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness)), morbid obesity (severely overweight), lumbago (lower back pain), with sciatica (pain affecting the back hip, and outside of the leg, caused by compression of a spinal nerve root in the lower back) of the right side, chronic peripheral venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin…

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 The facility reported a census of 25 residents. The sample of 14 residents included one resident (R)4 for respiratory care. Based on observation, interview, and record review, the facility failed to provide R 4 needed respiratory care, consistent with professional standards of practice related to nebulizer treatment/care (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece). Findings included: - Review of the Resident (R)4's, Physician Orders, dated 04/13/22, revealed diagnoses which included asthma ( a respiratory condition marked by spasms in the bronchi of the lungs causing difficulty breathing usually resulting from an allergic reaction or hypersensitivity) and chronic obstructive pulmonary disease (COPD) with acute exacerbation (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set (MDS) dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 25 resident with 14 residents sampled which included five residents sampled for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's recommendation in a timely manner to resolve identified irregularities for two residents, Resident (R)4 related to a recommended medication change and gradual dose reduction (GDR) of an antipsychotic medication for R 4 and R 9, related to GDR for psychoactive medications and recommended lab work. Findings Included: - Review of the Resident's (R)4's, Physician Orders, dated 04/13/22, revealed diagnoses which included lewy body dementia (a disease associated with abnormal deposits of a protein in the brain. Called Lewy bodies, affect chemicals in the brain whose changes, in turn can lead to problems with thinking, movement, behavior , and mood), with behavioral disturbances, anxiety disorder (fear characterized by behavioral disturbances) major depressive disorder (abnormal…

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.