El Dorado Care And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure a safe environment for one resident, Resident (R) 22, who had multiple falls in the facility dining room, and failed to follow her plan of care. Findings included:- R22's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), atrial fibrillation (rapid heartbeat), and muscle weakness. The Quarterly 5-Day Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of eight, indicating moderately impaired cognition. R22 required partial staff assistance for eating, mobility, transfers, and did not ambulate. R22 had no functional impairment and had no falls since the prior assessment. The Quarterly MDS, dated 01/06/26, documented a BIMS of 8, indicating moderately…

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 facilitate the necessary dental care services for Resident (R)1. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and protein calorie malnutrition (a severe form of undernutrition caused by inadequate intake of protein, calories, and essential nutrients, or by high metabolic demand). R1's admission Minimum Data Set (MDS), dated [DATE], recorded R1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed R1 was independent with oral hygiene and personal care. The assessment revealed that R1 did not have any natural teeth or tooth fragments, no inflamed or bleeding gums, and no broken or loosely fitting full or partial dentures. R1's Dental Care Area Assessment (CAA), dated 03/06/26,…

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 had a census of 43 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines, placing the residents at risk for unmet nutritional needs. Findings included:- On 04/06/26 at 09:00AM, observation revealed R48 sat in a wheelchair in her room with the bedside table in front of her awaiting her breakfast tray. Continued observation revealed at 09:30 AM a nurse aide came into R48's room and R48 inquired when her breakfast would be delivered. The nurse aide stated the kitchen had not delivered the food cart to the hall and when they did, she would deliver R48's room tray. On 04/06/26 at 10:00 AM, observation revealed R48 sat in a wheelchair in her room with her bedside table in front of her awaiting breakfast to be delivered to her room On 04/06/26 at 10:05 AM, Administrative Nurse D and Administrative Nurse E were summonsed to R48's room and the surveyor inquired when R48 would and should receive her breakfast and they stated…

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 37 residents. The sample included eight residents who were reviewed for misappropriation. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1, R2, and R3 remained free from misappropriation when staff wrote checks and forged signatures to cash the checks without appropriate authorization.Findings included:- R1's Electronic Health Record (EHR) revealed diagnoses that included dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive communication deficit, generalized muscle weakness, and a need for assistance with personal care.R1's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The assessment documented that R1 had minimal difficulty hearing but did not have hearing aid devices. R1 required supervision or setup assistance with most activities of daily living (ADL).R1's Quarterly MDS dated…

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 34 residents with 14 residents selected for review, which included one resident reviewed for self-determination. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)5, received appropriate preparations for his scheduled surgery. Findings included: - Review of Resident (R)5's diagnoses included paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) due to demyelinating (a disease of the spinal cord, nerves and brain causing paralysis and weakness) disease of the central nervous system, and cutaneous (in the skin) abscess (cavity containing pus and surrounded by inflamed tissue) of the abdominal wall. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident had impairment in both lower extremities and no impairment in upper extremities. The Activities of Daily Living…

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 34 residents. The sample of 14 residents included three residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide two Residents (R), R27 and R 3, who required respiratory care, including tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) care and tracheal suctioning, provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences related to the storage of suctioning cannulas/tubing to when not in use to prevent infection and cross contamination to prevent infection. Findings included: - Review of Resident (R)27's Physician Orders, dated 08/07/24 revealed the following diagnoses that included spastic quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), cerebral palsy (progressive disorder 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 The facility reported a census of 34 residents. The sample of 14 residents included five residents reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure medications monitored and administered to treat Resident (R)19's heart failure. Findings included: - Review of Resident (R) 19's Physician Orders, dated 08/07/24, revealed diagnosis that included congestive heart failure. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The resident rejected evaluation of care one to three days a week. The Quarterly MDS, dated 06/21/24, documented changes in the resident status which included a BIMS score of 13, which represented a decline in his cognition. R 19's Care Plan dated 08/29/24, directed staff the resident received multiple medications to treat his diagnoses. The staff should administer medications as ordered, monitor for side effects and effectiveness,…

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 34 residents. Based on observation, record review, and interview, the facility failed to ensure foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents. Findings included: - Observation, on 09/30/24 at 10:02 AM, revealed the kitchen refrigerator contained six squirt bottles of condiments (salad dressings) that lacked coverings over the tips of the squirt bottles. Observation, on 10/02/24 at 10:57 AM, during environmental tour of the kitchen with Dietary Staff BB, revealed the following areas of concern: 1. The kitchen refrigerator contained six squirt bottles of condiments (salad dressings) that lacked coverings over the tips of the squirt bottles. 2. The kitchen handwashing sink contained a black substance along the back edge caulking and brown/yellow discolorations on the sink back edges. 3. The air fryer/convection oven contained splatters of a black substance on the upper interior surface. 4. The ice machine drain laid directly in the drain without a two-inch air gap. Interview, on 10/02/24 at 11:15…

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 34 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure staff provided incontinence care in a manner to prevent the spread of infection for one Resident (R)13 with an open wound on her sacrum (large triangular bone between the two hip bones). Findings included: - Review of Resident (R)13's medical record revealed diagnoses that included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, cerebral infarction (CVA/stroke) - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and sacral (large triangular bone between the two hip bones) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The Annual Minimum Data Set…

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 34 residents. Based on observation and interview, the facility failed to maintain patient care equipment in safe operating conditions to ensure two residents, Resident (R)82 and R2's commode grab bars and over the toilet commode. Findings included: - Observation, on 10/01/24 at 03:30 PM, revealed Resident (R)2's the over the toilet commode contained four legs that wobbled when pressure applied to the armrests, making it unstable. Observation, on 10/01/24 at 03:51 PM, revealed commode grab bars in Resident (R)82's bathroom, were unstable and moved when the resident attempted to sit or rise from the commode. Interview, on 10/01/24 at 04:00 PM, with Administrative Staff A stated she would expect staff to enter a maintenance request into their electronic system for maintenance tasks. The facility lacked a policy for maintenance of commode grab bars and over the toilet commode. The facility failed to ensure the commode grab bars for R82 and over the toilet commode for R2 were maintained in a safe condition to prevent accidents.

The facility reported a census of 37 residents. The sample included four residents sampled for quality of care. Based on observation, interview, and record review, the facility failed to ensure that three Residents(R)2, R 3, and R 4, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' choices, related to skin treatments for ostomies (an artificial opening in an organ created during an operation as ordered by the physician. Findings included: - Review of Resident (R)2's, undated Physician Orders, documentation revealed diagnoses which included quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), urinary tract infection, and retention of urine. The Annual Minimum Data Set, dated 07/13/23, documented the resident's short term and long-term memory intact. He had an indwelling catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence Care Area Assessment…

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 37 residents. The sample included four residents sampled for procedures of following physician orders. Based on observation, interview, and record review, the facility failed to ensure three Residents(R)2, R 3, and R 4, received treatment and care in accordance with physician's orders related to skin treatments for ostomies (an artificial opening in an organ created during an operation as ordered by the physician). Findings included: - Review of Resident (R)2's, undated Physician Orders, documentation revealed diagnoses which included quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), urinary tract infection, and retention of urine. The Annual Minimum Data Set, dated 07/13/23, documented the resident's short term and long-term memory intact. He had an indwelling catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Urinary Incontinence Care Area Assessment (CAA), dated 07/26/23, triggered secondary to use of a supra pubic…

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 35 residents. Based on observation and interview the facility failed to ensure a safe, clean, and homelike environment for the residents in the facility beauty shop, a resident hallway, the quiet room, and in the dining room. Findings included: - Observation, on 10/17/22 at 09:23 AM, with Maintenance Staff U, revealed the following areas of concern: The beauty shop contained a pink beautician's chair with a discolored grime covering all surfaces and tan/gray discolorations on the backrest top surface on each side approximately five by two inches. The base of the chair contained several areas of rusted surface. A corner of the floor contained loose cove base approximately four inches with soiled discolorations on the floor tile in this corner. The ceiling contained areas of stainage approximately 12 by 12 inches. The hair dryer filter contained a layer of dust across the entire surface. The threshold to a resident hallway contained an accumulation of discolored grime and the carpet in this hallway contained stains ranging in size of approximately…

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 35 residents. Based on observation and interview, the facility failed to ensure an environment as free of accident hazards as possible when the facility failed to ensure portable oxygen tanks were kept in a secure upright position. Findings included: - Observation, on 10/13/22 at 10:00 AM, revealed a portable oxygen cylinder with nasal canula tubing attached, positioned near the inside dining room door to the patio. This oxygen cylinder lacked a stabilizing base or cart to ensure stability. Observation, on 10/13/22 at 10:24 AM, revealed Administrative Nurse D, placed the portable oxygen cylinder on the back holder of an unsampled resident's wheelchair who had been outside on the patio smoking. Observation, on 10/17/22 at 11:30 AM, revealed a portable oxygen cylinder leaning against a bookcase in Resident (R)1 room. The cylinder lacked a stabilizing base or cart to ensure stability. Observation, on 10/17/22 at 11:40 AM, revealed a portable oxygen tank sitting across a chair in R 11's room. Interview, on 10/17/22 at 12:01 PM, with Administrative 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 The facility reported a census of 35 residents with 16 residents sampled. The facility failed to complete a baseline care plan to include the need for assistance with oral hygiene needs for one (R)137 sampled resident. Findings included: - Review of Resident (R)137's electronic medical record (EMR), included a diagnosis of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident required total assistance of one staff for personal hygiene and had no dental issues. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/07/22, did not trigger for further review. The baseline care plan, dated 10/05/22, lacked staff instruction for ADLs which also included the resident's need for assistance with oral hygiene cares. Review of the resident's EMR, from 10/04/22 through 10/18/22, revealed the resident…

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 35 residents with 16 residents sampled, including four residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide adequate hygiene cares for two fo the four sampled residents including: dependent Resident (R)137, regarding oral hygiene cares and R31 with grooming of facial hairs. Findings included: - Review of Resident (R)137's electronic medical record (EMR), included a diagnosis of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident required total assistance of one staff for personal hygiene and had no dental issues. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 10/07/22, did not trigger for further review. The baseline care plan, dated 10/05/22, lacked staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 35 residents with 16 residents sampled, including one resident reviewed for wheelchair positioning. Based on observation, interview, and record review, the facility failed to provide adequate body alignment of foot support for the one sampled dependent Resident (R)20, while in her wheelchair. Findings included: - Review of Resident (R)20's electronic medical record (EMR), included a diagnosis of cerebral accident (CVA or stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required total assistance of two staff for transfers and one staff for locomotion on the unit. She had no limitation in range of motion (ROM) and used a wheelchair. The Activities of Daily Living (ADL) Functional/Rehabilitation…

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 35 residents with 16 selected for review which included four residents reviewed for urinary catheter/urinary tract infection. Based on observation, interview and record review, the facility failed to ensure secure placement of a urinary catheter for one Resident (R)31 of the four residents reviewed. Findings included: - Review of Resident (R)31's Physician Order Sheet, undated, revealed diagnoses included cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), reflux uropathy (blockage of the normal flow of urine), urinary retention (when urine does not drain for the bladder), and history of e coli sepsis (severe infection with a type of bacteria known as Escherichia coli which is the most common cause of urinary tract infections). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function and required extensive assistance of two…

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 35 residents with 16 residents sampled, including one resident reviewed for tube feeding and weight. Based on observation, interview and record review, the facility failed to ensure staff gave the correct higher calorie physician ordered formula to the one sampled tube feeding Resident (R)137, which resulted in a 4.07% (percent) weight loss. Findings included: - Review of Resident (R)137's electronic medical record (EMR), included the following diagnoses: traumatic subdural hemorrhage (bleeding in the area between the brain and the skull) and type II diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. He required total assistance of one staff for eating and received 51% or more of his total calories through the tube feeding. He weighed 163 pounds. The Feeding Tube Care Area Assessment…

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 35 residents with 16 residents sampled, including one resident reviewed for respiratory. Based on observation, interview, and record review, the facility failed to ensure a clean, sanitary storage of the one sampled Resident's (R)11 bilevel positive airway pressure mask (BIPAP-a device that helps with breathing), to prevent respiratory infections. Findings included: - Review of Resident (R)11's electronic medical record (EMR), included a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. He required total assistance of two staff for bed mobility and transfers. He had shortness of breath (SOB) with exertion and when lying flat. The Activities of Daily Living (ADL)…

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 35 residents with 16 selected for review which included six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure staff followed medication administration holding parameters for one of the six sampled residents, Resident (R)25. Findings included: - Review of Resident (R)25's Physician Order Sheet, dated 10/01/22, revealed diagnoses that included hypertension (elevated blood pressure) and ateriosclerotic heart disease (thickening and hardening of the arteries of the heart). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function and received seven days of a diuretic (medication to reduce excess fluid in the body) within the seven-day look-back period. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/20/22, assessed the resident had impaired balance and transition during transfers and functional…

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 35 residents with 16 selected for review which included six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility consulting pharmacist failed to identify the lack of the facility following physician order parameters for holding the administration of antihypertensive medications for one Resident (R)25, of the six residents reviewed for unnecessary medications. Findings included: - Review of Resident (R)25's Physician Order Sheet, dated 10/01/22, revealed diagnoses that included hypertension (elevated blood pressure) and ateriosclerotic heart disease (thickening and hardening of the arteries of the heart). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognitive function and received seven days of a diuretic (medication to reduce excess fluid in the body) within the seven-day look-back period. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment…

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.