Adviniacare At Northbridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy and record review the facility failed to ensure that Transmission-Based Precautions (TBP: infection control measures used in addition to standard precautions [infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status] for patients who may be infected with certain infectious agents) were implemented for one Resident (#36) out of a total sample of 21 residents. Specifically, the facility staff failed to follow Contact Precautions (refers to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) for Resident #36 whose urine was infected with extended-spectrum beta-lactamase (ESBL: an enzyme found in some bacteria that is resistant to many antibiotic treatments, and associated with poor outcomes) producing bacteria, resulting in risk for transmission of infection to others. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy and record review, the facility failed to provide a Pneumococcal (bacteria often found in the nose and throat, is transmissible to others, and can cause infection) Vaccine to one Resident (#9) out of five applicable residents, out of a total sample of 21 residents. Specifically, the facility staff failed to provide a Pneumococcal Vaccine to Resident #9 when the Resident had previously received Pneumococcal Vaccine doses, was not up-to-date with his/her Pneumococcal Vaccine status, and consented to receive the Pneumococcal Vaccine when it was offered to him/her by the facility. Findings include: Review of the facility's policy titled, Pneumococcal Vaccination, dated 7/2019 and revised 2/2023, indicated: -All residents will be offered Pneumococcal Vaccines to aid in preventing Pneumonia/Pneumococcal infections. -The facility will offer Penumococcal Vaccination to all admitted residents, [AGE] years of age and older, unless such resident has already received vaccination, is not in need 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.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) who had a court appointed a legal Guardian, the Facility failed to ensure they notified Resident #1's Guardian that Resident #1 refused his/her daily antipsychotic medication and meals for several days, and that Resident #1 was transferred to the Hospital. Findings include: The Facility Resident Rights Policy, dated as last revised 10/2022, indicated that Federal and State laws guaranteed certain basic rights to residents which included, appointing a legal representative, to be notified of his/her medical condition and to be informed of and participate in his/her care planning and treatment. The Facility Notifications Policy, dated as revised 1/2023, indicated that except in a medical emergency, the Facility must notify the resident's designated representative when there is a significant improvement or decline in the resident's physical, mental or psychosocial status, a need to alter treatment significantly or a decision to transfer or discharge the resident from the Facility. Review 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.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to permit Resident #1 to remain in the Facility or to ensure that, prior to discharge, Resident #1's Physician documented the danger posed by the Facility's failure to discharge Resident #1 and the Resident's needs which could not be met in the Facility, as required. Findings include: The Facility Discharge/Transfer Policy, dated as revised 10/2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - a) the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility; - b) the transfer or discharge is appropriate because the Resident's health had improved; - c) the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident; - d) the health of individuals in the Facility would otherwise be endangered; - e) the resident has failed after reasonable and appropriate notice to pay for the stay at the…

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

Based on interviews and records reviewed, for one of three sampled resident (Resident #1) the Facility failed to provide a properly completed written Notice of Transfer or Discharge to the resident/resident's representative at the time the Facility initiated discharge for Resident #1, in accordance with the Federal regulations and per Facility Policy. Findings include: The Facility Discharge/Transfer Policy, dated as revised 10/2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - a) the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility; - b) the transfer or discharge is appropriate because the Resident's health had improved; - c) the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident; - d) the health of individuals in the Facility would otherwise be endangered; - e) the resident has failed after reasonable and appropriate notice to pay for the stay at the Facility; - f) 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 interviews and records reviewed, for one of three sampled residents (Resident #1), who had a court appointed legal Guardian who specified to Facility staff that if needed that Resident #1 be transferred to the closest hospital (which was only 10 miles away,) the Facility failed to ensure Resident #1's transfer was safe and orderly when, on 3/12/24 a physician order was obtained by nursing for Resident #1 to be transferred to the Hospital Emergency Department (ED) for evaluation however, the Facility instead discharged Resident #1 to an ED approximately 60 miles away, alone via a wheelchair van with all of his/her personal belongings. Findings include: The Facility Resident Rights Policy, dated as revised 10/2022, indicated staff members would treat residents with respect. The Policy indicated that Federal and State laws guaranteed certain basic rights to all residents, which included the right to participate in decision-making regarding their care. The Facility Care Plans Policy, dated as revised 1/2023, indicated each resident of the Facility would be involved in the…

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

Based on interviews and records reviewed for one of three sampled residents (Resident #1), who had a court appointed legal Guardian, the Facility failed to ensure the Guardian was provided with a written notice which specified the duration of the Facility Bed-hold Policy at the time of Resident #1's transfer to the hospital on 3/12/24, as required. Findings include: The Facility Bed Hold Policy, dated as revised 10/2022, indicated that it was the policy of the Facility to provide the resident, responsible party or legal representative with notice of the Facility's Bed Hold Policy at the time of transfer from the Facility to ensure continuity of care and residence post therapeutic leave or hospitalization. The Policy indicated it applied to all residents regardless of payor source and indicated that a written notice including the duration of the State bed hold policy and the reserve bed payment policy would be provided to the resident and/or representative. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her…

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

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to permit Resident #1 to return following an evaluation in the emergency department (ED) when on 03/12/24, the Facility considered Resident #1 discharged at the time of the transfer. Findings include: The Facility Discharge/Transfer Policy, dated as revised 10/2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: - a) the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility; - b) the transfer or discharge is appropriate because the Resident's health had improved; - c) the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident; - d) the health of individuals in the Facility would otherwise be endangered; - e) the resident has failed after reasonable and appropriate notice to pay for the stay at the Facility; - f) the Facility ceased to operate, or, - g) the transfer/discharge is…

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 records reviewed, for one of three sampled residents (Resident #1), who had a court appointed legal Guardian and complex mental health needs, the Facility failed to ensure they developed an effective discharge plan that addressed his/her needs and availability of services, prior to discharge, as required. Findings include: The Facility Discharge/Transfer Process Policy, dated as revised 10/2022, indicated that that Facility interdisciplinary team and the physician would regularly review a resident's potential for discharge and/or need to transfer to an alternate setting. The Policy indicated that a physician order was required in cases on non-emergent discharge. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the court appointed the Guardian for Resident #1 during April 2023. The admission Minimum Data Set (MDS) Assessment, 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.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) for whom the Facility initiated a discharge, the Facility failed to ensure completion of a discharge summary that included a recapitulation of the Resident #1's stay, course of illness/treatment or therapy, final summary of his/her status and a post-discharge plan of care developed with the participation of Resident #1 and the Guardian, as required. Findings include: The Facility Discharge/Transfer Process Policy, dated as revised 10/2022, indicated that that Facility interdisciplinary team and the physician would regularly review a resident's potential for discharge and/or need to transfer to an alternate setting. The Policy indicated that a physician order was required to discharge a resident in non-emergent cases. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. The Record indicated the…

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

Based on interviews and records reviewed, for one of three sampled residents (Resident #1) whose diagnoses included severe Obsessive Compulsive Disorder (OCD, OCD is a mental disorder that affects a person's brain and behavior which causes excessive thoughts that lead to repetitive behaviors and often centers on themes such as a fear of germs and commonly causes food aversion) the Facility failed to ensure Resident #1 received and was provided appropriate Behavioral Health services that addressed and met his/her mental health needs. Findings include: The Facility Behavioral Health Services Policy, dated as revised 10/2022, indicated the Facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the resident's assessment and plan of care. The Facility Psychiatric Services Policy, dated as reviewed 1/2023, indicated that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the…

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

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained compliance with regulation 258 CMR 20.00 relating to Professional Standards for social workers when, between 3/06/24 and 3/12/24, the Licensed Social Work Associate (LSWA) documented four Progress Notes in Resident #1's electronic health record (EHR) using the name (and therefore credentials) of the Licensed Independent Certified Social Worker (LICSW) Findings include: The Facility Social Worker Job Description indicates the social worker assumes the lead role in the delivery of psychological, financial, religious and physical needs of the resident, family members and significant others and assures resident's needs are met in accordance with policy and procedures of the facility. The Facility Charting and Documentation Policy, dated as revised 1/2023, indicated that all services provided to residents, or any changes in the resident's medical or mental condition are documented in the resident's medical record and should include the signature and…

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 records reviewed, for one of three sampled Residents (Resident #1), the Facility failed to ensure they maintained accurate and complete medical records related to social services, when documentation for services provided by a staff member for social services in Resident #1's electronic health record (EHR) was signed under another contracted staff member's name and professional credentials. Findings include: The Facility Charting and Documentation Policy, dated as revised 1/2023, indicated that all services provided to residents, or any changes in the resident's medical or mental condition are documented in the resident's medical record. The Procedure indicated entries may be recorded only by licensed personnel and should include the signature and title of the individual documenting. Review of Resident #1's medical record indicated that he/she was admitted to the Facility during March 2024 and his/her diagnoses included obsessive compulsive personality disorder, adult failure to thrive, delusional disorder and unspecified psychosis. Review of Resident #1'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.

Based on record review and interview, the facility failed to accurately execute Advanced Directives (written statement of a person's wishes regarding medical treatment) for one Resident (#24) out of a total sample of 21 residents. Specifically, the facility staff failed to include the invoked (activated) designated Health Care Proxy (HCP- an appointed individual who could legally make medical decisions on a person's behalf when he/she became unable to do so) regarding the decision making process for Resident #24, when completing a Medical Order for Life Sustaining Treatment (MOLST - a standardized medical order form for use by Clinician's caring for patients) form. Findings include: Resident #24 was admitted to the facility in November 2022 with diagnoses including Toxic Encephalopathy (brain dysfunction) and Depression. Review of the Resident's MOLST form dated 11/1/22 and signed by the Resident, indicated that he/she wished to be resuscitated in the event of cardiac or respiratory arrest. Review of the Minimum Data Set (MDS) assessment, dated 11/4/22, indicated the Resident was…

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 that two Residents (#47 and #28) out of a total sample of 21 residents, and/or Resident Representatives were included in the care planning process. Specifically, the facility failed to provide evidence that Resident's #47 and #28, and/or Resident Representatives had been invited to, and participated in their care plan meetings. Findings include: 1) Resident #47 was admitted to the facility in May 2021. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #47 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15. During an interview on 4/23/23 at 11:38 A.M., Resident #47 said that he/she does not get invited to any meetings at the facility and does not meet with any facility staff except the Physician. During an interview on 4/25/23 at 10:26 A.M., Social Worker (SW) #2 said that care plan meeting documentation was found in the progress notes section of the clinical…

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 policy review, observation, and interview, the facility failed to provide an adequate level of assistance to prevent an accident for one Resident (#74), out of a total sample of 21 residents. Specifically, the facility staff failed to ensure that Resident #74's coffee was re-heated in a safe manner and temperature checked before providing to Resident #74 per facility policy. Findings include: Review of the facility's policy, titled Food Re-heating, dated January 2023, included the following: - To reduce the risk of resident burns related to hot beverages, liquids and food, and to provide guidance on re-heating resident food and/or liquids. - Staff members only are to re-heat resident food and/or liquids in the microwave to temperatures that are safe and palatable for residents. - Locate the dial thermometer available in the re-heating area . - The staff member is to use the dial thermometer to ensure the item or liquid reaches 165 degrees Fahrenheit (F) to prevent foodborne illness. Temperature should be checked in at least two places. - Allow food to stand for minimum 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.

Based on observation, record review, and interview, the facility failed to ensure professional standards of care regarding respiratory equipment for one Resident (#11) out of a total sample of 21 residents. Specifically, the facility failed to: -obtain a Physician's order for oxygen use, -properly store respiratory equipment and change oxygen tubing timely to prevent contamination and infection. Findings include: Review of the facility policy for Oxygen Therapy, last revised 10/2022, indicated that: -Oxygen is administered according to Physician order. -Tubing change-oxygen cannula tubing .is changed weekly and as needed. Resident #11 was admitted to the facility in January 2023 with diagnoses including Acute and Chronic Respiratory Failure. Review of Resident #11's care plan with a start date of 1/20/23 indicated that Resident #11 was a new admission with weakness impacting his/her ability to care for self, status post acute COPD exacerbation (a worsening of chronic obstructive pulmonary disease symptoms). Further review of the care plan indicated an approach for Oxygen therapy as…

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, record review and interview, the facility failed to ensure its staff provided a Physician ordered medication for one Resident (#20) out of a total sample of 21 residents. Specifically, the facility failed to provide Potassium Chloride (a medication used to help regulate fluid balance, muscle contraction and nerve signals) 20 milliequivalent (mEq) over five consecutively ordered dates in April 2023. Findings include: Resident #20 was admitted to the facility in April 2020 with diagnosis of Acute Respiratory Failure with Hypoxia (low oxygen). Review of the April 2023 Physician's orders indicated an order for Potassium Chloride 10 meq -administer 20 mEq once a day every Sunday, Tuesday, Wednesday, Thursday and Saturday. On 4/25/23 at 7:50 A.M., during the medication pass, the surveyor observed Nurse #20 prepare medications for Resident #20. Nurse #2 prepared several medications for Resident #20 but omitted the Potassium Chloride. Review of the April 2023 Medication Administration Record (MAR), indicated that Potassium Chloride 20 mEq dose had been documented as…

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

Based on record review and interview, the facility failed to ensure limited use of a PRN (as needed) antipsychotic (used to treat psychosis [mental disorder characterized by a disconnection from reality]) medication to 14 days for one Resident (#23) out of a total sample of 21 residents. Specifically, the facility failed to ensure its staff limited the use of Haloperidol (antipsychotic medication) to 14 days when it was ordered by the Physician on a PRN basis and the Resident received the medication. Findings include: Review of the facility's policy, titled Psychotropic Medication, dated October 2022, included: PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. Resident #23 was admitted to the facility in March 2023 with diagnoses including Vascular Dementia and psychotic disorder with delusions (belief in something that is untrue) due to known psychological condition. Review of current Physician's orders, initiated 3/31/23, indicated: Haloperidol…

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

Based on observation, interview and policy review, the facility failed to ensure its staff adhered to sanitary standards of practice during food distribution in the main kitchen. Specifically, the facility failed to ensure dietary staff wore hair restraints that fully covered their hair during meal service. Findings include: Review of the facility policy titled Employee Sanitary Practices 2013 indicated the following: - All kitchen employees will practice standard sanitary procedures. - Wear hair restraints to prevent hair from contacting food. During an observation and interview on 4/23/23 at 7:30 A.M., the surveyor observed Dietary Staff #1 working in front of the grill in the main kitchen without a hair restraint in place. Dietary Staff #1 said that she was supposed to have a hairnet on while she worked in the kitchen but she forgot to put one on when she came to work today. During an observation and interview on 4/23/23 at 7:40 A.M., while in the facility main kitchen, the surveyor and the Food Service Director (FSD) observed Dietary Staff #2 to have long unrestrained hair…

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 policy review, record review and interview, the facility failed to ensure that its staff administered the influenza vaccine after obtaining consent for one Resident (#1) out of five applicable sampled residents. Findings include: Resident #1 was admitted to the facility in January 2023. Review of the facility policy titled Influenza Vaccination, last reviewed 2/3/22, indicated that annual vaccination is recommended for all persons aged 6 months and older. Review of the Consent for Immunizations, signed and dated 1/23/23, indicated that Resident #1 signed the consent to receive the influenza vaccine. Review of the clinical record did not indicate that Resident #1 had received, and been offered the influenza vaccine since admission to the facility. During an interview on 4/16/23 at 12:56 P.M., the Infection Preventionist said that the influenza vaccine had not been administered to Resident #1 as required.

Based on observation and interview, the facility failed to ensue a safe environment was provided for residents, visitors and staff. Specifically, the facility staff failed to properly secure Liquid Propane Gas (LPG) cylinders in the courtyard near the main dining room of the facility. During an observation and interview on 4/24/23 at 12:55 P.M., the surveyor observed three unsecured LPG cylinders on the ground near a barbecue grill, and in close proximity to patio chairs available for smokers outside in the courtyard near the entrance to the main dining room. The Assistant Director of Nurses (ADON) said that the courtyard area was designated as the resident smoking area of the facility and that the residents who smoked were supervised by staff in the courtyard during scheduled smoking times. The Administrator also said that in the good weather visitors can accompany residents to the courtyard. During a follow-up observation and interview on 4/24/23 at 4:05 P.M., the Administrator and the surveyor observed the same three LPG cylinders, unsecured, resting on the ground near a barbecue…

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.