Resorts At Chester River Manor Corp

Based on medical record review and staff interview it was determined that the facility failed to provide pain management as prescribed. This was evident for 1 (Resident #109) of 1 resident reviewed for pain management during the recertification/complaint survey.The findings include:Resident #109's Representative (RP) filed complaint #2580649 regarding the resident's pain management. The RP stated that the resident had been prescribed by the medical personnel pain medication for the large pressure ulcers (PU) and the pain incurred when the resident received treatment for these PU. On 12/15/2025 at 1:00pm, after reviewing the medical record and an interview with the Director of Nursing it was discovered that Resident #109 was not receiving the Tramadol medication every 8 hours as prescribed and the 2 pm dose was signed off on the Medication Administration Record (MAR) as being given but when the Medication Administration Record was compared with the Narcotics Record it was evident that the Tramadol had not been given. The missing Tramadol dates were 8/4-8/8/2025.When the Director 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, facility staff interview and surveyor record review it was determined that the facility failed to ensure that the posted nurse staffing information document displayed the required information. This finding was found to be evident in the review of sufficient and competent nurse staffing during the recertification/complaint survey. The findings include:The facility's staffing data document may be a form or spreadsheet, and all the required information displayed clearly and in a visible place. The information should be displayed in a prominent place that was readily accessible to Residents, staff and visitors and presented in a clear and readable format. This information posted must be up to date and current. The facility must post the nurse staffing data on a daily basis at the beginning of each shift. The facility must ensure staffing information was accurate and current. The data requirements for the daily posted nurse staffing information document must include facility name, current date, the total number and actual hours worked per shift for licensed 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 surveyor record review, review of consultation notes and Resident and staff interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This finding was found to be evident in 4 (Resident # 6, #33, #59, and #112) out of 41 Residents reviewed for identifiable information in the Resident medical records during the recertification/complaint survey. The findings include: A Medication Administration Record (MAR) is a legal document used by healthcare professionals to track all medications administered to a Resident. It is a crucial component of a Resident's medical chart, serving to ensure patient safety, accountability, and communication among care teams. The purpose of the MAR is to ensure safe and accurate medication management by providing a clear, trackable history of every medication dose given or missed. A Care Plan is a written document that outlines a person'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 observation, and interviews, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was found evident on 2 (Resident #6 & #70) out of 2 observations of medication administration during the recertification/complaint survey.The findings include:1) On 12/9/25 at 8:34 AM, the surveyor observed Licensed Practical Nurse (LPN) #12 prepare medications to be administered to Resident #6. The medications were gathered from a shared medication cart. LPN #12 gathered medications from multiple drawers and bottles. After preparing the medications the surveyor observed LPN #12 walk into Resident #6's room, move a wheelchair and table, and then administer medications. No hand hygiene was utilized before administering the medications.On exiting Resident #6's room the surveyor asked LPN #12 if it is the expectation to perform hand hygiene prior to providing medications to the Resident. He confirmed hand hygiene should be performed before medications are given.2) On 12/9/25 at 9:20 AM, the surveyor observed Licensed Practical Nurse…

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

Based on observations and interviews it was determined that the facility failed to provide a safe, functional, sanitary environment for a resident. This was found in 1 (Resident #59) of 26 Resident rooms reviewed in the initial sample during the recertification/complaint survey.The findings include:On 12/08/2025 at 9:26 AM, the surveyor observed Resident #59's bathroom. The toilet had what appeared to be urine in the toilet bowl. The surveyor noted that around the bowl, on the bathroom floor, it was wet. Resident #59 stated that the toilet had been leaking for some time and that the facility was aware it was leaking. Resident #59 asked the surveyor to flush the toilet and see that it continued to leak. When the surveyor flushed the toilet, the toilet leaked additional water onto the bathroom floor.On 12/08/25 at 11:42 AM, the surveyor interviewed the Maintenance Director Staff #10. During the interview Staff #10 stated he was aware the toilet was leaking and that he had ordered the parts to repair it. He further stated that he was going to repair the toilet today now that the parts…

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 the medical record review and staff interview it was determined the facility failed to keep complete and accurate medical records. This deficient practice was evident in 7 of 20 (#37, #42, #58, #5, #10, #77, #24) resident during the survey. The findings include: 1. During observation rounds on 03/05/24 at 11:21 am Resident #37 made the surveyor aware his/her wheelchair was too large and the wheelchair cushion was too small. On 03/06/24 at 9:51 am during an interview with Director of Rehabilitation #18, he/she verbalized the rehab staff measures the wheelchair to make sure it's a proper fit. When asked if the facility provided the resident with a wheelchair, he/she verbalized needing to check and follow-up. On 03/06/24 at 1:06 pm the surveyor received documentation from Rehab Director #18 which was an occupational therapy evaluation for Resident #37. Rehab Director #18 verbalized the resident's wheelchair and cushion were appropriate for Resident #37 when discharged from rehab services. Upon review of the documentation the surveyor noticed the form did not indicate 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 observation and interview with facility staff, it was determined that the facility failed to maintain the dignity and privacy of a resident as evidenced by the resident's nephrostomy bags left uncovered while outside of their room. This was evident for 1 (Resident # 193) of 86 residents that were observed during the survey. The findings include: A nephrostomy is a small tube inserted through the skin directly into the kidney to allow urine to drain from the kidney into a collecting bag outside the body. It is surgically placed by a healthcare provider if a person's urine cannot leave their body due to kidney stones, kidney infection, trauma, or other reasons. During an observation that took place on 3/5/24 at 10:40 AM, Resident #193 was in the Terrace Lounge during a social coffee time with both nephrostomy bags uncovered, leaving the resident's urine visible to view through the clear bags. On 3/5/24 at 10:41 AM, in an interview conducted with Licensed Practical Nurse (LPN #29), she stated that when a resident comes out of their room, their nephrostomy bags 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 and interviews it was determined the facility staff failed to ensure that residents' call bells were in reach to request assistance. This deficient practice was evident in 2 of 8 (Resident #32 and Resident #58) residents assessed for call bell accommodations during the survey. The findings include: On 03/04/24, at 9:14 am during observation rounds the surveyor entered room [ROOM NUMBER]. Resident #32 was sitting on the side of the bed. The surveyor noticed that the call bell was draped over the bedside table and was not in the resident's reach. The surveyor greeted Resident #58 and noticed that the call bell was on the floor near the left side of the bed. On 03/04/24 at 9:19 am Social Worker#7 confirmed the surveyor's findings. On 03/06/24 at 12:49 pm during an interview with Director of Nursing #2 who verbalized the managers make rounds twice in the morning and twice in the evening before leaving. It was expected for the call bell to be always assessable to the residents. The Geriatric…

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 with facility staff it was determined the facility failed to ensure that scheduled pain medications for a resident were not misappropriated. This was found to be evident during a medication drug storage review and narcotic review and reconciliation for 1 of 3 medication carts reviewed during the survey. Findings include: During a review of a medication cart on the Osprey Unit with nurse (#27), a Licensed Practical Nurse (LPN) on 3/7/24 at 2:30 PM, the following concerns were identified while reviewing the narcotic drawer: The nurse counted the medication blister pack of Tramadol Tablet 50 mg for Resident # 5. There were 7 pills observed inside of the blister pack. At that time the surveyor and the nurse reviewed the controlled drug receipt record/disposition form. There was an entry on 3/7/24 at 0900 indicating that 1 tablet was given and 6 tablets were left with, a signature entry by the nurse. On the same date at 2:55 PM an interview was conducted with Resident # 5 who was sitting up in bed in their room, was asked if s/he was having any pain…

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 medical record review and interviews it was determined that the facility staff failed to generate a person-centered care plan for a resident who required assistance with dental care. This deficient practice was evident in 1(Resident #35) of 5 resident records reviewed for person centered care plans during the survey. The findings include: On 03/05/24 at 10:22 am during an interview with Resident #35 he/she verbalized needing to see the dentist. On 03/06/24 at 11:58 am the surveyor received copies of Resident #35's dental visits; the last dental visit was 05/25/23. Continued review revealed a 12/19/22 dental summary recommendation to assist the resident with teeth brushing. The surveyor reviewed the resident's care plans which revealed assisting the resident with tooth brushing was not included in the ADL care plan. On 03/06/24 at 3:26 pm during an interview Director of Nursing (DON) #2 verbalized the Minimum Data Set Coordinator(MDS) initiates the baseline care plan. Each team does their own care plans. Whatever triggers out has a care plan. Anything acute that happens 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 medical record review and interview it was determined that the facility staff failed to have quarterly care plan meetings. This deficient practiced was evidenced in 1 (#73) of 3 resident records reviewed for care plan meetings during the survey. The findings include: On 03/05/24 at 12:32 pm a review of Resident #73's electronic medical record (EMR) revealed the last care plan meeting was held 09/02/23. On 03/05/24 3:05 pm during an interview with Social Worker #7 revealed care plan meetings are held quarterly and as needed. Social worker #7 receives a list monthly of residents whose care plans meeting are due. They usually have the meetings on Tuesday. An invite is sent the week beforehand to the responsible party (RP) and resident. They set-up a time either on the phone or in person. Therapy, Activities, Social Services and the resident's Responsible party usually attends the meetings and Nursing will come if available. Afterwards they sign the attendance form. Social worker #7 advised she is working on getting all the care plan meetings done.

Based on a review of the medication administration audit record (MAAR) and interview with facility staff, it was determined the facility staff failed to document after administering medications to residents. This was evident for 1 (Residents #32) of 6 residents reviewed for timely medication administration. The findings include: The surveyor reviewed the MAARs for Resident #32 on 3/7/24 at 2:07 PM for the period of 3/1/24 to 3/6/24. The MAAR is a document that shows the time that a medication is documented as being administered when staff documents it in the computer. Upon review of the MAAR, Resident #32's medications were documented as administered late. The surveyor interviewed Licensed Practical Nurse (LPN #23) on 3/6/24 at 3:50 PM, who was identified as documenting medication administration late. During the interview, when asked about medication administration for Resident #32 on 3/4/24, they had omeprazole scheduled for 8:00 AM and the documented administration time in the MAAR was 3/4/24 at 11:44 AM. LPN #23 stated the resident did get their medication on time, it is usually…

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 with facility staff it was determined the facility failed to: 1.) ensure that a resident (#5) received a scheduled dose of medication as ordered by the physician; 2.) ensure medications were signed off on the controlled drug receipt/disposition form after being administered to a resident (#10). This was evident during a medication drug storage review and narcotic review and reconciliation for 1 of 3 medication carts; and 3) administer scheduled medications to residents at the physician ordered time (Resident #32, Resident #23, Resident #42). This was evident for 3 (Residents #32, #23, #42) of 6 residents reviewed during a medication administration observation Findings include: 1. During a review of a medication cart on the Osprey Unit with nurse (#27), a Licensed Practical Nurse (LPN) on 3/7/24 at 2:30 PM, the following concerns were identified while reviewing the narcotic drawer: a. The nurse counted the medication blister pack of Tramadol Tablet 50 mg for Resident # 5. There were 7 pills observed inside of the blister pack. At that time 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 medical record review and staff interviews, it was determined the physician failed to evaluate a resident with a change in condition in a timely manner. This was evident for 1 of 6 sampled residents (Resident #24) during the survey. The findings include: During observation rounds on Quail Unit on 3/4/24 at 9am, Resident #24 stated, s/he had a terrible a sore throat. S/he stated, I told the nurse. During a follow up visit on 3/5/24 at 10am the resident stated, My throat is still sore, and I want to see the doctor. This surveyor observed the Nurse Practitioner (NP) (staff # 21) sitting at the desk on Quail Unit at 10:15am on 3/5/24. This surveyor informed staff #21 of the resident complaint. She stated, I will add the resident to my list of residents to see. On 3/6/24 at 10:30am during an interview with the Unit Manager (staff #14) she was asked why the resident complaint of sore throat was not addressed on 3/4/24. She stated that Resident #24 did not tell the nurse that s/he had a sore throat. On 3/5/24 at 1pm during an interview with the NP staff #21 stated she was 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 medication administration observation, medical record review and staff interview, it was determined that the facility staff failed to ensure a medication error rate of less than 5% during the medication observation facility task. This was evident for 5 of 27 medications administered during the observation which resulted in an error rate of 18.52%. The findings include: 1. During a medication administration observation that took place on 3/6/24 at 10:38 AM, the surveyor observed Licensed Practical Nurses (LPN #23) administer medications to Resident #32. The medications included one capsule of Omeprazole 20mg (milligrams) and one puff of Fluticasone-Salmeterol 250-50 mcg/act (micrograms/actuation). LPN #23 failed to provide instructions to Resident #32 regarding rinsing the mouth after administration, and Resident #32 did not rinse his/her mouth after receiving the dose. Review of the medical record on 3/6/24 at 11:31 AM for Resident #32 revealed a physician order dated 1/30/23 for Fluticasone-Salmeterol 250-50 MCG/ACT Aerosol Powder, breath activated, Give 1 puff by mouth…

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 medication administration observation and staff interview, it was determined that the facility staff failed to adhere to infection control practices and guidelines to prevent and control transmission of infectious agents during medication administration. This was evident for 2 of 27 medications administered during the medication administration observation. The findings include: 1. During a medication administration observation that took place on 3/6/24 at 10:48 AM, Licensed Practical Nurse (LPN #23) was observed dispensing Resident #42's medications, Seroquel 50mg and Celexa 10mg, into a medication cup, putting both tablets into a pill crusher located on top of the medication cart, crushing the tablets together, and pouring the crushed medications into a different medication cup filled with pudding. During this process, LPN #23 stated she crushes both medications together and mixes them with pudding because if she does not, Resident #42 will spit them out. The surveyor did not observe the nurse clean the tablet crusher after its use nor for the remainder of the medication…

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 medical record review and interviews it was determined that the facility staff failed to offer and administer the pneumococcal vaccine to a resident. This deficient practice was evidenced in 1 (#40) in 5 resident records reviewed for immunizations during the survey. The findings include: According to the Center for Disease Control website, there are certain risk conditions that warrant an individual to receive the pneumonia vaccine for adults ages of 19 - [AGE] years of age. These conditions are but not limited to alcoholism or cigarette smoking, chronic liver disease, Diabetes Mellitus, chronic heart disease (including CHF & cardiomyopathies), decreased immune function from disease or drugs, and chronic lung disease, including COPD, emphysema, and asthma. On 03/07/24 at 4:50 pm the surveyor reviewed the facility's immunization report which revealed Resident #40 received the Pneumococcal Conjugate 13 vaccine on 06/26/12. The surveyor reviewed the resident's electronic medical record (EMR) which revealed…

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, it was determined that facility's food service employees failed to ensure that equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 4/22/2019 at 8:34 AM, an initial tour of the facility's kitchen was conducted. The following observations were made: 1. The paper towel dispenser for the hand sink adjacent to the gas stove was observed without any towels available to dry washed hands. 2. Empty plastic wrappers, trash and an open saltine cracker packet were observed on the floor of the dry goods storage room. The Director of Food Service and Administrator were made aware of these findings on 4/25/2019.

Based on medical record review and interview, the facility staff failed to honor a resident's choices (Resident #16). This was evident for 1 out of 40 residents reviewed during the survey process. The findings include: During interview with Resident #16 on 4/24/19 at 12:20 PM, he/she stated he/she would like to receive snacks daily but the facility staff do not always provide. Review of the resident's medical record revealed on 4/15/19 the resident was seen by the dietitian. At that time the dietitian documented, Family is requesting resident receives between meal snacks due to hunger complaints. Nurse made aware. Further review of the medical record revealed no physician order for snacks. After surveyor intervention, the facility staff obtained the following physician order on 4/25/19: Resident may have afternoon and every evening snack. Per resident request. Interview with the Director of Nursing on 4/25/19 at 12:50 PM confirmed the surveyor's findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation during the initial tour of the facility it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The findings include: 1. On 4/22/2019 at 10:29 AM, room [ROOM NUMBER] was observed to have dried stains on the floor and on feeding tube equipment present in the room. 2. On 4/23/2019 at 8:57 AM, room [ROOM NUMBER] was observed having crumbs on the floor by the closet. The crumbs had been observed during the initial tour on 4/22/2019 at 10:29 AM. The bedside table was observed with old, dried spills on the table legs. The Director of Nursing and Director of Maintenance were made aware of these findings on 4/29/2019.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that facility staff failed to notify a resident's representative in writing of a transfer to the hospital. This was evident for 3 of 40 residents (Resident #23, Resident #53, Resident #66) reviewed during survey investigation. The findings include: Resident #23's medical record was reviewed on 4/23/2019. This review revealed that Resident #23 was transferred to the hospital on 3/19/2019. There was no documentation in the medical record to indicate that Resident #23's representative was given written notice of the transfer. Resident #53's medical record was reviewed on 4/25/2019. This review revealed that Resident #53 was transferred to the hospital on 4/2/2019. There was no documentation in the medical record to indicate that Resident #53's representative was given written notice of the transfer. Resident #66's medical record was reviewed on 4/23/2019. This review revealed that Resident #66 was transferred to the hospital on [DATE]. There 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.

Based on staff interview and medical record review it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 2 of 40 residents (Residents #37 and #53) reviewed during survey investigation. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Care Plans are comprised of a Focus, Outcome and Interventions/Tasks to help guide care for residents. 1.) On 4/26/2019 a review of Resident #37's Care Plan revealed an Outcome that stated Resident on hospice, weight maintenance is top priority. This Outcome was written on 2/18/2019 by the facility Dietician. Hospice is a specialized type of care for residents whom doctors estimate have 6 months or less to live. Further review of the medical record revealed a progress note from 3/5/2019 that stated the resident was no longer on hospice care as of 2/12/2019. The Assistant Director of Nursing (ADON) was interviewed on 4/26/2019 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 medical record review and staff interview it was determined the facility failed to follow the physician's orders for no weights, vitals or labs for a resident. This was evident for 1 of 40 residents (Resident #37) reviewed during the survey investigation. The findings include: Review of the medical record for Resident #37 on 4/25/2019 revealed a current physician order for No wts (weights), V/S (vitals) or labs created on 1/29/2018. Further review of the medical record showed that Resident #37's weight was taken on 4/8/2019. The Assistant Director of Nursing (ADON) was interviewed on 4/26/2019. The ADON stated that the weight on 4/8/2019 was taken as a baseline measurement after Resident #37 was removed from hospice care. However, review of the medical record on 4/26/19 established that Resident #37 was removed from hospice care on 2/12/2019. The Director of Nursing and Administrator were made aware of these findings on 4/26/2019. See F 656

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to follow the recommendations of the dietitian. This was evident for 1 out of 40 residents (Resident #44) reviewed during the survey process. The findings include: Review of Resident #44's medical record revealed the resident was seen by the dietitian on 3/9/19 for weight loss. The dietitian documented at that time, Weight loss noted, supplement in place and appetite stimulant ordered. Recommend resident started on fortified foods and bi-weekly weights to monitor closely. Review of the resident's medical record revealed the resident was ordered fortified foods but the resident was not weighed again until 4/1/19, not biweekly as recommended. Further review of Resident #44's medical record revealed the resident was in the hospital from [DATE] until 4/19/19. On 4/19/19 the physician ordered a regular puree texture diet. On 4/20/19 the resident was seen by the dietitian who documented, Registered dietitian to recommend patient continues to…

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 medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for a resident. This was evident for 1 of 40 residents (Resident #61) reviewed during the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #61's medical record revealed the Resident had a physician order on 4/18/19 for laboratory tests (CBC, CMP, Lipid Panel, TSH and Uric Acid) to be completed on 4/23/19. Further review of the Resident's medical record on 4/29/19 at 9:18 AM with Assistant Director of Nursing revealed the laboratory tests results were not in the medical record. After surveyor intervention, the Assistant Director of Nursing was able to obtain the results of the laboratory tests and included them in the medical record on 4/29/19.…

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.