Enterprise Estates Nuring Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 27 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to obtain adequate blood samples for Resident (R) 6 's laboratory testing and further failed to obtain physician involvement for direction related to continued Coumadin (anticoagulant-blood thinning drug) and Lovenox (anticoagulant-blood thinning drug) administration without the required monitoring. Findings included: - R6's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke) affecting right dominant side, aphasia (condition with disordered or absent language function), hypertension (elevated blood pressure), and atrial fibrillation (rapid, irregular pulse). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R6 required staff assistance with activities of daily living, reported no pain, and received anticoagulant…

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 31 residents. The sample included 14 residents. Based on record review and interview, the facility failed to implement a water management program for waterborne pathogens including the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). This placed the residents in the facility at risk for infectious disease. Findings included: - On 01/16/34 at 03:42 PM, Maintenance Staff U stated he took over the position a couple of months ago and did not know anything about the water management process. He stated it was not implemented. On 01/17/24 at 02:45 PM, Administrative Staff A stated Maintenance Staff U probably did not know the building was at risk for Legionella. The facility's Water Management policy dated 06/20/23, documented the director of environmental services was responsible for all relevant details regarding roles…

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 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to properly store medication and biologicals in one of two medication rooms. This placed the residents at risk of ineffective medication. Findings included: - On 01/16/24 at 02:46 PM, observation revealed the north hall medication refrigerator lacked evidence staff assessed and recorded temperatures from 01/11/24 through 01/15/24 (five days). Licensed Nurse (LN) H stated it was the night shift nurses' responsibility to check and log the refrigerator temperature. On 01/17/23 at 01:47 PM Administrative Nurse D verified the medication refrigerator temperature should have been checked daily and recorded on the log. The facility's Monitoring of Refrigerators and Freezers policy, dated 10/09/23, documented that medicine or drug refrigerators will be kept solely for the purpose of storing medications that require refrigeration according to the manufacturer's instruction. Refrigerators containing vaccines will have temperature 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.

The facility identified a census of 31 residents. The sample included 14 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination, or a physician-documented contraindication for pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - Review of Resident (R) 5, R7, R18, R19, and R24's clinical medical records lacked evidence of consent, informed declination, or physician-documented contraindication for the current pneumococcal vaccine PCV20. On 01/16/24 at 12:00 PM, Administrative Nurse E stated she had faxed the doctors about the PCV20 in November to talk about it when they came in for nursing…

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 had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 4, for her diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), supplemental oxygen use and R5's care related to a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin. This placed the residents at risk for impaired care due to uncommunicated care needs. - The Electronic Medical Record (EMR) for R4 documented diagnoses of COPD and shortness of breath. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had severely impaired cognition and was dependent upon staff for toileting and showers. R4 required substantial to maximum assistance for mobility and partial to moderate…

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 31 residents. The sample included 14 residents with seven reviewed for behaviors. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered interventions for behavioral triggers for one resident, Resident (R) 14, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). This placed the resident at risk for decreased quality of life due to uncommunicated care needs, Findings included: - The Electronic Medical Record for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and PTSD. The Quarterly Minimum Data Set (MDS), 11/22/23, documented R14 had intact cognition and was dependent…

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 had a census of 31 residents. The sample included 14 residents, with one reviewed for edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Based on observation, record review, and interview, the facility failed to notify the physician as ordered for Resident (R)3's weight increase. This placed the resident at risk for complications related to edema. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema, hypertension (high blood pressure), and dyspnea (difficulty breathing). The admission Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and required limited to extensive assistance from two staff for activities of daily living (ADL). The assessment further documented R3 was short of breath upon exertion, when resting, and lying flat.…

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 had a census of 31 residents. The sample included 14 residents, with two reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide adequate respiratory care and services for Residents (R) 3 and R4 when staff failed to store their oxygen tubing and cannula in a sanitary manner when not in use. This placed the residents at increased risk for an infection. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema, hypertension (high blood pressure), and dyspnea (difficulty breathing). The admission Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and required limited to extensive assistance of two staff for activities of daily living (ADL). The assessment further documented R3 was short of breath upon exertion, 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 had a census of 31 residents. The sample included 14 residents, with seven reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma informed care assessment for Resident (R)14, who had a diagnosis of post -traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). This placed the resident at risk for unmet behavioral and mental health needs. Findings included: - The Electronic Medical Record for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and PTSD. The Quarterly Minimum Data Set (MDS), 11/22/23, documented R14 had intact cognition and was dependent on staff for transfers, toileting, showers, and required substantial…

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 had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to notify Resident (R) 5's physician of elevated blood sugar per the physician ordered parameters and failed to initiate R19's prescribed bowel treatment which placed both resident at risk for impaired care and adverse medications effects. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), diabetes melilites (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin)with kidney complications and neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), pain, hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), dementia (progressive mental disorder characterized…

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 had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple attempts for nonpharmacological symptom management and risk versus benefits to continue the use of an antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) for Resident (R) 9 who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion), R7 who had diagnoses of dementia and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and R19 with a diagnosis of depression. This placed the residents at risk for unnecessary psychotropic (alters mood or thoughts) medications and related complications. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of dementia, anxiety (mental or emotional reaction…

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 interview and record review, the facility failed to ensure principles of antibiotic stewardship were followed to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner. Findings included: -Review of the Infection Control Tracking Log for tracking and trending infections from May 2021 through May 2022, revealed lack of Infection Control Logs for July 2021, September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, and May 2022. The Infection Control logs reviewed lacked complete data for analysis of adherence with an evidenced-based surveillance criterion to define infections and effectiveness of the facility's antibiotic stewardship program. The logs revealed incomplete documentation of culture results of organism identification for monitoring trends in infections. An interview on 06/06/22 at 08:37 AM with Administrative Nurse E identified herself as the facility Infection Preventionist…

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 identified a census of 34 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 06/07/22 at 08:31 AM, Administrative Nurse E stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse further stated she was going through the training but had not completed it yet. On 06/07/22 at 05:23 PM Administrative Staff A stated that the former Director of Nursing had an Infection Preventionist Certification and the previous Minimum Data Set (MDS) Coordinator also had a certification. The facility had been without a certified Infection Preventionist for about a month. The Infection Control Policy approved 01/04/19 documented the infection…

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 identified a census of 34 residents. The sample included 12 residents. Two residents were sampled for elopement. Based on observation, record review and interview the facility failed to provide adequate supervision for cognitively impaired Resident (R) 15 to prevent an elopement (when a cognitively impaired resident leaves the facility without staff supervision or knowledge). The facility failed to determine a root cause analysis for falls and failed to ensure preventive measures where in place to prevent further falls for resident (R)17, and R13. And the facility lacked a recent smoking assessment for R20. This placed R15 at risk for accidents and related injuries and put R17, R13, and R20 at risk for injury and or/harm. Findings included: - The electronic medical record (EMR) for R15 documented the following diagnoses: dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion and behaviors), and major depressive disorder, severe with psychotic…

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 identified a census of 34 residents. The facility had seven residents in quarantine due to a positive COVID-19 (a highly contagious severe acute respiratory illness) virus status. The sample included 12 residents. Based on observation, record review and interview, the facility failed to ensure staff properly donned (put on) the required personal protective equipment (PPE-gowns, gloves, mask, and eye protection) and disposed of PPE after use, failed to monitor resident's temperature and respiratory status daily during an outbreak of the COVID-19, and failed to ensure that staff appropriately sanitized, cleaned, and maintained designated resident COVID-19 quarantine areas. This placed facility residents at risk for possible COVID-19 transmission and severe respiratory complications. Findings included: - On 06/07/22 at 12:30 PM Licensed Nurse (LN) K wore an KN95 (a mask made of synthetic material used to protect from outside particles) mask as she pushed a cart with disposable meal containers and disposable cups with lids down the north hall to COVID here R15 and R24's…

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 identified a census of 34 residents. The sample included 12 residents. Resident (R)15 was sampled for reporting of an alleged violation. Based on observation, record review and interview, the facility failed to ensure that an incident of potential neglect was reported to the state agency in the required timeframe and failed to submit the incident investigation in the required timeframe. This placed R15 at risk for ongoing neglect and inadequate cares. Findings included: - The electronic medical record (EMR) for R15 documented the following diagnoses: dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion and behaviors), and major depressive disorder, severe with psychotic symptoms (a mental disorder in which a person has depression along with loss of touch with reality). The Significant Change Minimum Date Set (MDS) dated [DATE] documented R15 had a Brief Interview for Mental Status (BIMS) score of one which indicated severely impaired cognition.…

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 identified a census of 34 residents. The sample included 12 residents with 12 residents reviewed for development of comprehensive care plan. Based on observation, record review, and interviews, the facility failed to develop person-centered comprehensive care plans for Resident (R) 13 related to dementia (progressive mental disorder characterized by failing memory, confusion) care and services. This deficient practice placed them at risk for increased behaviors, confusion, and decline in ability to maintain the highest practicable mental and psychosocial well-being. Findings included: - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental…

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 identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to revise the person-centered care plan with appropriate interventions to prevent future falls for Resident (R) 13 and R17, which placed these residents at risk for future falls and related injuries. Findings included: - R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R13 required limited assistance of one staff member for activities of daily living (ADL's). The MDS for R13 documented no behaviors…

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 identified a census of 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident (R) 23 for lack of appropriate diagnosis for medication administration. The facility failed to follow the CP recommendation for physician documentation of benefit and continued use it of an as needed (PRN) antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment testing) and other mental emotional conditions) and antianxiety medication (class of medications that calm and relax people with excessive anxiety, (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) nervousness, or tension) for R23. This deficient practice placed R23 at risk for the potential of unnecessary medication administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure appropriate diagnosis for medication administration for Resident (R) 23, and failed to ensure consitent bowel monitoring was completed for R13, which placed R23 and R13 at risk for the potential of unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R23's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), The admission Minimum Data Set (MDS) dated [DATE] documented severely impaired cognition per 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 identified a census of 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure physician documentation of risk versus benefit for continued use it of an as needed (PRN) antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment testing) and other mental emotional conditions) and antianxiety medication (class of medications that calm and relax people with excessive anxiety, (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) nervousness, or tension) for R23. This deficient practice placed R23 at risk for the potential of unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R23's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder…

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.