Chestnut Woods Rehabilitation And Healthcare Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement the plan of care related to assistance with meals for one Resident, (#36), out of a total sample of 21 residents. Findings include: Review of the facility's Care Plans, Comprehensive Person Centered policy, dated March 2022 indicated: Policy statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. Resident #36 was admitted to the facility in June of 2022 with diagnoses including dementia and weakness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #36 scored 5 out of a possible 15 on the 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 observation, record review and interview, the facility failed to meet professional standards of quality for four Residents (#49, #15, #42 and #17), out of a total sample of 21 residents. Specifically: 1) For Resident #49 the facility failed to follow physician orders for weekly skin checks. 2) For Resident #15 the facility failed to complete skin checks as ordered. 3) For Resident #42 the facility failed to implement air mattress setting as indicated in the physician order. 4) For Resident #17 the facility failed to to obtain weekly weights according to physician's order. Findings Include: Review of the facility policy, titled Assessment of Skin Condition and Integrity, adopted March 2021, indicated, but was not limited to, the following: Skin Assessment: 1) Conduct a comprehensive head-to-toe skin assessment upon admission, weekly, prior to discharge and as needed. a.) During the skin assessment, inspect for: i. Presence of skin impairment(s); ii. Type of skin impairment(s); and iii. Location of skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation record review and interview, the facility failed to provide necessary treatment and care for one Resident (#33) out of a total of 21 sampled residents. Specifically, the facility failed to ensure treatment orders were initiated for Resident #33's skin tears. Findings include: Review of the Wound Treatment policy, dated April 2024, indicated: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. Resident #33 was re-admitted to the facility in September 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance with bathing and dressing. During an interview on 9/10/24 at 8:57 A.M., the surveyor…

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 physicians orders and care plans related to the use of a catheter were implemented for one Resident (#33) out of a total of 21 sampled residents. Findings include: Review of the Urinary Incontinence - Clinical Protocol policy dated April 2018 indicated: Assessment and Recognition: As part of the initial assessment, the physician will help identify individuals with impaired urinary continence. For example, review of a hospital discharge summary may reveal that the individual was incontinent with or without catheter placement during a recent hospitalization. Resident #33 was initially admitted to the facility in August 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency. Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance toileting and did not have an indwelling…

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, policy review and interviews, the facility failed to provide care and maintenance of a peripheral inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#237), out of a total sample of 21 residents. Specifically, the facility failed to implement dressing changes routinely as required. Findings include: Review of the facility policy titled 'Central Venous Catheter Care and Dressing Changes' dated March 2022, indicated the following but not limited to: -Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g, damp, loosened or visibly soiled). -Maintain sterile dressing ( transparent semi-permeable membrane (TSM) dressing or sterile gauze for all central vascular access devices. The type of dressing is based on the condition of then resident and his or her preference. -Change the dressing if it becomes damp loosened or visibly soiled and: a. Every seven days for TSM…

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, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#7) who had a history of trauma out of a total sample of 21 residents. Specifically, for Resident #7, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings include: Review of the facility policy titled Trauma Informed and Culturally Competent Care, dated 8/2022, indicated the following: Purpose: -To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. -To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: - Trigger is a psychological stimulus and prompts recall of a previous traumatic event, even if the stimuli itself is not traumatic or frightening. Resident Care Planning: -Develop and individualized care plan that addresses past trauma in collaboration with the resident and family, as appropriate. -Identify 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure that one Resident (#64) was free from significant medication errors out of a total sample of 21 residents. Specifically, the nurses did not administer the wrong dispensed dosage of Trazadone (an antidepressant). Findings include: Review of the facility policy titled 'Administering Medications' revised April 2019, indicated the following but not limited to: -If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences the person preparing or administering the medication will contact the prescriber the residents attending physician or the facilities medical director to discuss the concerns. -The individual administering the medication checks the label three times to verify the right resident right medication right dosage right time right method route of 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 Based on observations, policy review, and interview the facility failed to ensure medications with short expirations dates were dated when opened. Findings include: Review of the facility policy titled 'Medication Labeling and Storage' revised February 2023, indicated the following but not limited to: *Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. *Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. 1. During an inspection of the [NAME] unit on 9/12/24 at 6:35 A.M., the following medications were available for administration: - Two incruse Ellipta inhalers 62.5 (mcg) microgram inhalation powder opened and undated. - One Advair 100/50 mcg opened and undated. - One Advair 250/50 mcg opened and undated. - One albuterol sulfate 90 mcg opened and undated. - One Symbicort inhaler 80-4.5mcg opened and undated. - One…

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: 1. ensure medication administration was accurately documented for two Residents (#33 and #35) and 2. failed to accurately document blood pressure readings for one Resident (#37) out of a total of 21 sampled Residents. Findings include: 1a. Resident #33 was re-admitted to the facility in September 2024 with diagnoses including chronic obstructive pulmonary disease, dysphagia and venous insufficiency. Review of the Minimum Data Set Assessment (MDS) 8/26/24 indicated Resident #33 scored 15 out of a possible 15 on the Brief Interview for Mental Status exam (MDS) indicating intact cognition. The MDS also indicated Resident #33 requires assistance with bathing, dressing and toileting. Review of the September 2024 Medication Administrative Record (MAR) indicated the following medication were not documented as administered on the 7:00 A.M. - 3:00 P.M. shift on 9/8/24: Aripiprazole (an antipsychotic medication) Oral Tablet 5 MG: Give one tablet by mouth one…

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 1. ensure staff initiated and followed Enhanced Barrier Precautions for one Resident (#33) out of a total of 21 sampled residents, and 2. failed to ensure shared medical equipment was properly cleaned between the use of residents during the medication pass. Findings include: Review of the Enhanced Barrier Precautions policy, dated August 2022 indicated: 1. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not apply otherwise. Gloves and gown are applied prior to performing high contact resident care activity (as opposed to entering the room). 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: dressing, transferring, device care or use (central line, urinary catheter, feeding tube, etc); wound care. 6. EBPs remain in…

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 records reviewed and interviews for one for three sampled residents (Resident #1), whose Physician's Orders included the administration of an injectable medication used to treat schizophrenia, the Facility failed to ensure the Physician was promptly notified when Resident #1's medication was not administered as ordered. Findings Include: The Facility Policy titled Change in a Resident's Condition or Status, undated, indicated that the nurse will notify the resident's attending Physician when there has been a need to alter the resident's medical treatment significantly. The Policy indicated that regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. Resident #1 was admitted to the Facility in July 2015, diagnoses included major depressive disorder, adult failure to thrive, auditory hallucinations, anxiety, and paranoid schizophrenia. Review of Resident #1's Physician's Orders, dated 10/05/23, indicated he/she was to be administered Invega Sustenna…

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 records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for administration of an anti-psychotic medication once every twenty-eight days, the Facility failed to ensure he/she was free from a significant medication error when he/she was not administered two doses of his/her anti-psychotic medication, placing him/her at risk for an adverse reaction related to a sudden stop in the medication. Findings Include: The Facility Policy titled Administering Medications, dated as revised April 2019, indicated that medications are administered in a safe and timely manner and in accordance with prescriber orders, including any required time frame. Review of the Drugs.com article related to Invega Sustenna injections, dated August 2023, indicated the following: The medication is an extended release (long acting) medication given by intramuscular injection and used to treat schizophrenia. The article indicated when starting the medication one dose is administered, the second dose a week later, and there after, only one dose each month…

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 records reviewed and interviews for one of two sampled residents (Resident #1), the Facility failed to ensure they maintained complete and accurate Medical Records when Resident #1's Medication Administration Record (MAR) was not consistently completed during the month of December 2023. Findings Include: The Facility Policy titled Charting and Documentation, dated as revised 07/2017, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The Policy indicated that medications administered and treatments or services performed were to be documented in the resident medical record. The Policy indicated documentation of procedures and treatments would include care specific details such as the date and time the procedure/treatment was provided, whether the resident refused the procedure/treatment, and signature and title of the individual documenting. Resident #1 was admitted to the Facility in July 2015,…

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 policy review, observations, interviews and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for one Resident (#2) out of a total sample of 24 residents. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, last revised 3/18, indicated the following: Policy Statement: *Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. Policy Interpretation and Implementation: *2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: D. dining (meals and snack)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to provide the necessary treatment and services to prevent the development and promote healing of pressure ulcers for one Residents (#49) out of a total of 24 sampled residents. Resident #49 was admitted to the facility in August 2023 with diagnoses unsteadiness on feet, unstageable pressure ulcer of left buttock, unspecified protein calorie malnutrition and gastrostomy. Review of Resident #49's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 10 out of possible 15 indicating moderate cognitive impairment. The MDS further indicated Resident #49 had one of more unhealed pressure ulcers at stage one or higher. On 9/26/23 at 9:14 A.M., the surveyor observed Resident #49 sitting up in bed, a dressing wrapped the left foot and no Prevalon boots (a pressure relieving device for the heels) were observed. Additional observations were made by the surveyor on 9/26/23 at 4:03 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide behavioral health services as recommended by the behavioral health service Nurse Practitioner for one Resident (#20) out of a total sample of 24 residents. Findings include: Resident #20 was admitted to the facility in December 2022 with diagnoses including sepsis, anxiety disorder, major depressive disorder with severe psychotic features. Review of Resident #20's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #20 had no behaviors. During an observation on 9/26/23 at 9:17 A.M., Resident #20 was observed lying in bed. Resident #20 told the surveyor the course of events requiring him/her to be in the facility. Resident #20 began crying while talking with the surveyor and expressed being sad. Resident #20 said he/she used to have someone that would come into…

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 recommendations from the Monthly Medication Review conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for one Resident (#30) out of a total sample of 24 Residents. Findings include: Review of the facility policy titled Medication Regimen Reviews, undated, indicated the following: *The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication at least monthly. *Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident, the report contains: the resident's name, the name of the medication, the identified irregularity and the pharmacist's recommendation. *If the physician does not provide a timely response or adequate response, the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or administrator. *The attending physician documents in the medical record that the irregularity has been reviewed 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 observations, record reviews, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5 percent. Two out of two nurses observed made three errors in 31 opportunities on one of two units resulting in a medication error rate of 9.68%. These errors impacted two Residents (#74 and #27), out of five residents observed. Findings include: Review of the facility policy titled 'Administering Medications' revised April 2019, indicated the following but not limited to: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation *Medications must be administered in accordance with the orders, including any required time frame. * The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. During a medication pass on 9/27/23 at 9:16 A.M., the surveyor observed Nurse #1 prepare 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 observations, policy review, and interview the facility failed to ensure medications with short expirations dates, were dated when opened, on two out of four medication carts. Findings include: Review of the facility policy titled 'Medication Labeling and Storage' revised February 2023, indicated the following but not limited to: *Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. *Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. 1. During an inspection of SCU medication cart on 9/27/23 at 9:40 A.M., the following medications were available for administration: -3 Fluticasone furoate/vilanterol elipta inhalation powder 100 mcg (micrograms)/ 25 mcg, opened and undated hence unable to determine the expiration date. -1 Fluticasone propionate nasal spray 50 mcg opened and undated. During an interview on 9/27/23 at 9:43 A.M., Nurse #1 said inhalers and nasal sprays should be…

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, interview and record review, the facility failed to provide dental services for two Residents (#6 and #30) out of a total sample of 24 residents. 1. Resident #6 has had multiple admissions, most recently admitted to the facility in September 2022, with diagnoses including dysphagia (difficulty swallowing), and cerebral infarct. Review of Resident #6's most recent Minimum Data Set (MDS) dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, indicating he/she has moderate cognitive impairments. The MDS also indicated Resident #6 requires extensive assistance of one person for all self-care activities. During an interview on 9/26/23 at 9:07 A.M., Resident #6 said his/her dentures had been missing for a few months. Resident #6 was asked if he/she told staff, he/she said yes. Review of Resident #6's medical record indicated he/she has an oral/dental health care plan initiated on 6/15/23 indicating the following: *Focus: I am at risk…

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 properly store food items to prevent the risk of foodborne illness. Specifically, the facility failed to separate personal food items from resident food items in the walk-in refrigerator. Findings include: During the revisit to the kitchen on 9/27/23 at 11:38 A.M., the surveyor observed three cups of iced coffee with straws sticking out from the top stored in the walk-in refrigerator in the same area where resident food is stored. During an interview on 9/27/23 at 12:10 P.M., the Foodservice Director said personal food items should not be stored with resident food.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents ( #49 and #30) out of a total sample of 24 Residents. Specifically, 1) For Resident #49 the facility failed to (a) accurately document the application of prevalon boots and (b) accurately document the implementation of contact precautions. 2) For Resident #30, staff signed off on the Medication Administration Record (MAR) that the Resident was wearing a hand splint while the facility reported it missing and was not being worn by Resident #30. Findings include: 1 a. Resident #49 was admitted to the facility in August 2023 with diagnoses including unsteadiness on feet, unstageable pressure ulcer of left buttock, unspecified protein calorie malnutrition and gastrostomy. Review of Resident #49's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 10 out of possible 15 indicating moderate cognitive impairment. The MDS further…

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.