The Bradford Skilled Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility's video footage review, and interviews the facility failed to ensure a comprehensive, person-centered care plan had been developed and implemented for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure, Resident #4 was checked every two hours for incontinence. Findings: Review of Resident #4's medical record revealed an admit date of 07/17/2020 and reentry date of 05/28/2024 with diagnoses including, but not limited to, schizoaffective disorder bipolar type, Alzheimer's disease, history of falls, and osteoarthritis. Review of Resident #4's MDS (Minimum Data Set) dated 08/26/2024 revealed a BIMS (brief interview for mental status) score of 2 indicating severely impaired cognition. Review of Resident #4's comprehensive care plan revealed, in part, the problem of frequent bowel incontinence with intervention including, but not limited to, check resident every two hours. On 10/28/2024 at 2:00 p.m., review of facility's video footage from 10/21/2024 at 11:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to ensure a resident received ADL (Activities of Daily Living) care for 1 (Resident #3) out 4 (Residents #1, #2, #3, #4) residents reviewed. Findings: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part a primary diagnosis of muscle wasting and atrophy. Other diagnoses included COPD (Chronic Obstructive Pulmonary Disease), bronchitis, cough, anxiety, dysphagia, bipolar disorder, insomnia, hypertension, pain, and osteoporosis. Review of Resident #3's minimum data sheet dated 09/10/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 which would indicate the resident was cognitively intact. Review of Resident #3's comprehensive care plan revealed a care plan with a focus indicating the resident has an ADL self-care performance deficit related to decreased vision, impaired balance. Interventions included personal hygiene: resident requires assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents were treated with dignity and respect. The facility failed to address 1 resident (#1) out of 3 (#1, #2, #3) residents in a dignified and respectful manner. Findings: Review of Facility's Resident Rights Policy (revised October 4, 2022) revealed: Employees shall treat all residents with kindness, respect, and dignity .These rights include the resident's right to: a. a dignified existence; and c. be treated with respect, kindness, and dignity . Review of Resident #1's medical records revealed an admit date of 08/29/2024 and a discharge date of 08/31/2024 with the following diagnoses, including in part: Chronic Obstructive Pulmonary Disease (COPD)/unspecified, centrilobular emphysema, chronic respiratory failure with hypoxia, unspecified diastolic (congestive) heart failure, pneumonia/unspecified organism and pulmonary hypertension/unspecified. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure residents have a right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 (Resident #360) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints. The facility failed to ensure: 1.) a side rail utilization assessment was completed, 2.) a consent for the use of side rails was obtained, and 3.) a physician's order was in place for the use of bedrails for Resident #360. Review of facility's Use of Restraints policy with a revision date of April 2017 revealed in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline of staff convenience or for the prevention of falls. Policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails. The facility failed to assess residents for use of bed rails (side rails), obtain an informed consent from resident or resident representative prior to installation of bed rails, and/or obtain physician order for bed rails for 11 (#3, #17, #23, #41, #66, #68, #72, #78, #80, #88, #96) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints. Findings: Review of the facility's Proper Use of Side Rails policy with a revision date of January 16, 2024 revealed in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of the side rails as restraints unless necessary to treat a resident's medical symptoms. Definition Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method…

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

Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of 5% or greater by committing 2 errors (#19, #93) out of 29 opportunities for an error rate of 6.9%. Findings: Resident #19 Observation during medication pass on 08/20/2024 at 8:20 a.m. revealed S6 LPN (Licensed Practical Nurse) administered Fluticasone Propionate and Salmeterol 250mcg (microgram) /50mcg by oral inhalation to Resident #19. Review of Resident #19's current physician orders revealed a 07/16/2024 order for Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/act (actuation) (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease. During an interview on 08/20/2024 at 2:30 p.m. S6 LPN reviewed Resident #19's medication container from medication cart which read Fluticasone Propionate and Salmeterol 250mcg/50mcg and reviewed Resident #19's physician order and reported the medication was not administered as per the physician order…

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

Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of PBJ (Payroll Based Journal) [NAME] Report 1705D for the fiscal year 2024, 2nd quarter (January 1-March 31) revealed excessively low weekend staffing was triggered. During an interview on 08/22/2024 at 10:10 a.m S1 Administrator reported S5 Human Resources submits the agency staffing information to corporate and corporate submits PBJ report quarterly to CMS (Centers for Medicare & Medicaid Services). S1 Administrator reported the facility had adequate staff. S1 Administrator reported an agency invoice may have been missed or corporate may not have had the agency invoice at the time of reporting. During an interview on 08/22/2024 at 10:25 a.m. S5 Human Resources reported the PBJ staffing report is completed by the corporate office. S5 Human Resources reported when staffing agencies send staffing hours to the facility late, the staffing hours reported to corporate office will show that the facility did not have enough…

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

Based on observations and interview the facility failed to accommodate the needs of 1 (#78) of 26 sampled residents. The facility failed to ensure Resident #78's call light was within reach. Findings: Review of Resident #78's medical record revealed an admit date of 04/03/2024 with diagnoses that included, in part, parkinsonism, unspecified dementia with psychotic disturbance, type 2 diabetes mellitus, pain unspecified, restlessness and agitation, and insomnia. Review of Resident #78's 06/06/2024 Quarterly MDS (Minimum Data Set) revealed Resident #78 had a Brief Interview Mental Status (BIMS) of 03 which indicated a severe cognitive impairment and required extensive assistance with bed mobility, transfer, and toilet use. Observation on 08/19/2024 at 8:20 a.m. revealed Resident #78's call light was on the bedside table where Resident #78 could not reach it. During an interview on 08/19/2024 at 8:20 a.m. this surveyor asked Resident #78 if he could reach his call light and Resident #78 was observed feeling around on his bed and answered no. Observation on 08/19/2024 at 8:56 a.m.…

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

Based on record review and interviews the facility failed to ensure provision of services in compliance with all applicable Federal, State, and local laws, regulations and codes by failing to investigate an incident involving resident to staff violence for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to follow the facility's policy by failing to investigate a resident to staff verbal exchange that progressed to a physical exchange between Resident #1 and S6 LPN (Licensed Practical Nurse). Findings: Review of Workplace Aggression/Violence Policy revised April 2023 Policy Statement It is the policy of this facility that all employees, residents, family members, visitors, contractors, vendors, etc., enjoy a positive, respectful, productive and safe environment while on our premises. Policy Interpretation and Implementation 1. Workplace violence is defined as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty. Violent acts include, but are not limited to: a. Verbal or physical…

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

Based on observations, record reviews and interview, the facility failed to ensure 1 (Resident #3) of 3 (Resident #1, #2, #3) sampled residents was free of accidents and hazards. Findings: Review of Resident #3's medical records revealed admit date of 12/07/2023 with the following diagnoses, in part: muscle wasting and atrophy/multiples sites, other abnormalities of gait and mobility, other lack of coordination, anxiety disorder/unspecified, shortness of breath, Type 2 diabetes mellitus without complications, pain/unspecified, heart failure/unspecified, and pulmonary fibrosis/unspecified. Review of Resident #3's Comprehensive Care Plan revealed: risk for falls r/t (related to) gait/balance problems, Psychoactive drug use - fall mats x 2, keep bed in low position Be sure the resident's call light is within reach . Review of Resident #3's Physician's Orders revealed an order dated 04/09/2024 - patient to have low bed and fall mats. Observation on 04/15/2024 at 10:10 a.m. revealed Resident #3 lying in bed with call bell hanging off side of bed out of reach. Bed in high position.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a physician's order was entered correctly for one resident (#2) of four residents (#1, #2, #3, #4) that were sampled. Findings: Record review of Resident #2's physician telephone orders dated 08/03/2023 revealed, in part, an order for blood glucose checks daily in the a.m. and as needed. Record review of Resident #2's physician orders for August, September, October, and November 2023 revealed the following order, in part: An order with start date of 08/03/2023, Accucheck daily and as needed (blood sugar check). Humalog 100unit/milliliter subcutaneous solution inject subcutaneous per sliding scale finger stick before meals and hour of sleep (four times a day). Time code was for 6 a.m. Parameters, 0-60 hypoglycemic protocol; 61-199=0units; 200-250=2units; 251-300=4units; 301-350=6units; 351-400=9units; [PHONE NUMBER]=12units, recheck in one hour; if greater than 400 call MD (medical doctor). These orders should have read as, blood glucose checks…

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

Based on record reviews, observation, and interviews the facility failed to accommodate the needs and preferences of 3 (#4, R1, R2) of 7 (#1, #2, #3, #4, #5, R1, R2) residents who required needed assistance with ADL (Activities of Daily Living) that included transfers, toileting, bed mobility and eating. Findings: Review of the facility's Resident Call Light System Policy revealed, in part: Purpose: The purpose of this procedure is to respond to the resident's request and needs. Policy Implementation: A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities. Purpose: The call light system is activated in the resident's room, the light outside the door is checked and the panel light and volume are checked at the nurse's station to ensure it is working properly. Review of resident #4 clinical record revealed an admit date of 10/07/2023 with…

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

Based on interviews and record review the facility failed to ensure grievance were addressed and investigated for 1(#2) of 5 (#1, #2, #3, #4, #5) sample residents. The facility failed to follow their policy/procedures that was presented by the DON (Director of Nursing) for reporting and investigating grievances. Findings: Review of the facility Resident Grievances/Complaints policy - Staff Responsibility revealed the following: Policy Statement Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. Policy Interpretation and Implementation 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident, a resident's representative (sponsor), or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other resident, etc. the staff member is encouraged to guide the resident, or person acting on the resident's behalf, as to how to file a written complaint with the facility.…

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

Based on record reviews and interviews the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 4 (#2, #7, #18, #71) of 32 residents reviewed for advance directives. Findings: Review of facility's Advance Directives policy with a revision date of 05/31/2023 revealed in part: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Resident #2 Review of Resident #2's Medical Records failed to reveal and Advanced Directive. During an interview on 07/25/2023 at 11:15 a.m. S8 Corporate Nurse reported the facility is unable to produce…

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

Based on record review and an interview the facility failed to ensure resident's plan of care was reviewed and revised for 1 (#13) out of a total of 25 sampled residents reviewed for plan of care. The facility failed to revise the plan of care for Resident #13 to include refusal of house supplements. Findings: Review of Resident #13's medical record revealed a significant weight loss of 14.17 % in a six-month period. Review of Resident #13's current physician's orders revealed an order dated 04/18/2023 which read house supplement, give 90 mls. (milliliter) by mouth four times a day. Review of Resident #13's May 2023 - July 2023 Medicine Administration Records revealed Resident #13 refused house supplements on the following dates and times: 05/16/2023 at 8:00 p.m. 05/19/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 05/20/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 05/21/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 05/25/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 06/09/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. 06/21/2023 at 4:00 p.m. 06/24/2023 at 8:00 a.m., 12:00 p.m. and 4:00 p.m.…

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

Based on observations, record review, and interviews, the facility failed to ensure a resident who required assist with activities of daily living (adl) received the necessary services to maintain grooming and hygiene for 1 (#86) of 3 residents reviewed for activities of daily living. The facility failed to ensure Resident #86 received a shower in a timely manner. Findings: Review of facility's Shower/Tub Bath policy with a revision date of October 2010 revealed in part: The purpose of the procedures are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Review of Resident #86's MDS (Minimum Data Set) dated 06/26/2023 revealed Resident #86 required a one person assist for personal hygiene. Review of Resident #86's Bath Day Roster revealed Resident #86's shower record: 07/21/2023 at 11:20 a.m. - Friday - Shower (S11 CNA) 07/22/2023 at 2:23 p.m. - Saturday - Not scheduled bath day (S11 CNA) 07/23/2023 at 11:11 a.m. - Sunday - Not scheduled bath day (S11 CNA) 07/24/2023 at 1:32 p.m. - Monday - Not scheduled bath day (S10 CNA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure there was sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure that resident calls for help were answered timely and resident needs were met. Findings: Observation on 07/24/2023 9:30 a.m. revealed resident #18 called for assistance with the use of the call button, the light over resident #18's door came on. An audible call was overhead stating, room [ROOM NUMBER] needs assistance, at 9:35 a.m., 9:45 a.m., and 9:49 a.m., with no response. Further observation failed to reveal any visible staff on the hallway of resident #18's room at the time of resident #18's call for assistance and resident #18's light over the door remained on until 9:55 a.m., when a staff member entered resident #18's room. During an interview on…

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

Based on observations and interviews the facility failed to provide a safe, functional environment. The facility failed to ensure: 1. Toilets were securely attached to the floor in resident #209's, and resident #7's bathrooms. 2. Resident #24's faucet was attached securely to the bathroom sink 3. Clean out receptacle on 200 hall was warped, uneven and unleveled. Findings: Observation on 07/24/2023 at 8:00 a.m. revealed resident #209's toilet was not secured to the floor and moved around. During an interview on 07/26/2023 at 9:00 a.m. resident #209 reported her toilet was loose and shook when she sat on it. Observation on 07/24/2023 at 8:15 a.m. revealed resident #7's toilet was not secured to the floor and moved around. Observation on 07/24/2023 at 8:20 a.m. revealed resident #24's bathroom faucet was loose and moved around. Observation on 07/26/2023 at 9:10 a.m. with S4 Maintenance Supervisor revealed resident #209's and resident #7's toilets were not secured to the floor and moved around. Observation on 07/26/2023 at 9:15 a.m. with S4 Maintenance Supervisor revealed the clean out…

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

Based on observations and interviews, the facility failed to accommodate the needs of 2 (#73, #101) of 25 sampled residents observed for accommodation of needs. The facility failed to ensure the call light devices were in a position where they could be activated. Findings: Review of facility's Resident Call Light System with a revision date of June 2023 revealed in part: Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General guidelines: 4. Ensure that the call light is easily reachable by the resident Resident #73 Observation on 07/24/23 at 8:45 a.m. revealed Resident #73's call light lying on Resident #73's floor. During an interview on 07/24/2023, 8:45 a.m. Resident #73 reported she knew how to use the call light but could not reach it. Resident #101 Observation on 07/24/2023 at 9:00 a.m. revealed call light device lying on Resident #101's floor. During an interview on 07/24/2023 at 9:00 a.m., Resident #101 reported she knew how to use the call light but could not reach the device. During an interview on 07/24/2023 at 9:00 a.m., S2 ADON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the provider failed to complete an investigation for 1(Resident #68) of 1(Resident #68) residents after Resident #68 had an injury from an unknown origin. Findings: Review of the facility's policy for investigating injuries with a revision date of December 2016 revealed: Policy statement- The Administrator will ensure that all injuries are investigated. Policy interpretation and implementation revealed, in part: 1. The DON (director of nursing) or a designee will assess all injuries and document clinical findings in the clinical record. 2. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the Administrator and Director of Nursing Services. Review of the facility's Falls-Clinical Protocol with a revision date of March 2018 revealed the following, in part: Assessment and Recognition 2. The nurse shall assess and document/report 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 Based on observation and interviews, the facility failed to ensure resident's personal dietary choices were met for 1 (#92) out of 3 (#34, #209, #92) sampled residents reviewed for food. The facility served Resident #92's dislikes. Review of Resident #92's Medical Record revealed admit date [DATE]. Review of Resident #92's MDS (Minimum Data Set) assessment dated [DATE] revealed: Section C: Cognitive Patterns - BIMS (Brief Interview for Mental Status) 15 - intact cognition. During an interview on 07/24/2023 at 8:30 a.m. Resident #92 reported he filled out his dislikes and likes for the kitchen but they keep sending him squash and beets. Resident #92 further reported his dislikes, squash and beets, are on his dietary ticket but the kitchen doesn't pay attention and sends it anyway. Observation on 07/24/2023 at 12:15 p.m. revealed Resident #92's lunch tray contained squash in a bowl. Further observation revealed Resident #92's dietary ticket with dislikes as squash and beets. During an interview on 07/24/2023 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.