South River Rehabilitation and Wellness Center

Based on observation, medical record review and interviews, it was determined the facility staff failed to clarify and document appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (resident #10) of 1 resident reviewed for mobility. The findings include: A contracture is an abnormal shortening of muscle, tendons, skin, or tissues, causing the resistance to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand. On 3/13/26 at 7:36 AM, the surveyor observed Resident #10 resting in bed. His/her left hand was noted to be contracted, and no splint was applied or visible in the room. Next the surveyor reviewed Resident #10's orders. The review revealed two orders for a left hand splint. The first order was written on 5/29/26 that stated, nursing to don (apply) left hand splint following morning Activities of Daily Living (ADLs). The patient should be able to remove following about 4 hours and 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 record review and interviews with staff, it was determined that the primary medical provider failed to review the total program of care for 1 (Resident #11) out of 43 residents reviewed during the survey. The findings include: On 3/9/26 at 8:38 AM, the surveyor interviewed Resident #11. During the interview Resident #11 stated that he/she had recently been admitted to the facility after a hospital stay and alleged that the facility was not following his/her transplant drug regimen correctly. On 3/10/26 at 8:01 AM, the surveyor reviewed Resident #11's medical record. Review of Resident #11's discharge paperwork revealed Resident #11 was discharged to the facility on 2/19/26. The medications were ordered as recommended, however, in the course of stay from the hospital report it was noted that Resident #11's renal function was improving and stable but recommended that Resident #11 needed to have repeat labs such as a Basic Metabolic Panel (BMP) in 1 week. The discharge instructions stated, Labs Needed at Rehab: followed by, please check hematocrit and BMP weekly on Mondays…

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 record review, it was determined that the pharmacy failed to deliver the correct medication dosages to the facility. This was evident in 1 (Resident #95) out of 6 residents evaluated for accurate dispensing during the medication administration task. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The findings include: On 03/11/26 at 8:00 AM, the surveyor observed a discrepancy between Resident #95's Diazepam order and the pharmacy script. The resident's active order stated: Diazepam 2mg tablet. Give 1.5 tablets by mouth in the morning for anxiety. Please hold for sedation, while the script stated: Diazepam 2 mg tablet. Give 1 tablet by mouth in the morning for anxiety. The tablets in the bubble packet were only available in one strength and form, consisting of whole 2 mg tablets. On 03/11/26 at 8:03 AM, the surveyor interviewed Staff…

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

Based on observation, record review and interview, it was determined that the facility failed to ensure that a controlled medication was labeled and stored properly. This was evident for 1 (Resident #95) out of 6 residents observed during the medication administration task. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II—V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The findings include: On 03/11/26 at 8:00 AM, the surveyor observed a discrepancy in Resident #95's medication order. Staff #19 retrieved a bubble packet for Resident #95 labeled, Diazepam 2 mg tab. Give 1 tablet by mouth in the morning for anxiety. When the surveyor checked the order in the Medication Administration Record (MAR), the script on the medication bubble packet did not match the active order. The order on the bubble packet had been discontinued on 03/03/26, and the new order was initiated on 03/04/26. The active order was Diazepam 2mg. Give…

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 interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #9) of 1 resident reviewed for dental services during the survey. The findings include: On 3/9/26 at 8:10 AM, the surveyor interviewed Resident #9. During the interview Resident #9 stated that he/she was still waiting for the facility to follow up on making an appointment for his/her bottom teeth. On 3/11/26 at 7:30 AM, the surveyor reviewed Resident #9's medical record. The review revealed that a dental consult note written on 9/11/25 stated that Resident #9 was seen for a tooth extraction. The note stated that the resident was not able to tolerate the procedure and stated the safest course would be extractions under General anesthesia in the hospital setting. The recommendations were to refer Resident # 9 to Oral and Maxillofacial Surgery OMFS at a local hospital. On further review a dental note was written by…

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 Resident and staff interviews, observations and surveyor record review it was determined that the facility failed to ensure that a Resident's food preferences, food intolerances and food allergies were followed. This finding was found to be evident in 1 (Resident #41) out of 8 Residents reviewed for food and nutrition services.The findings include:On 3/9/2026 at 11:15 AM Resident #41 stated to the surveyor that he/she had a food intolerance to dairy products, but he/she continues to receive dairy products on the meal trays.The surveyor conducted a record review of Resident #41's medical record on 3/11/2026 at 10:45 AM. Review of the medical record revealed that Resident #41 had an allergy to dairy products as indicated on the physician orders/order summary report. Further review of the Diet History/Food Preferences assessment completed by the Food Services Director (FSD) on 2/11/2026 revealed that Resident #41 had a food allergy/intolerance to dairy products.In an interview with the FSD at 12:15 PM on 3/11/2026 he stated that Resident #41 had a food preference not 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 observations and facility staff interviews it was determined that the facility failed to ensure that garbage and refuse was maintained in a proper manner. This finding was found to be evident during the review of the outside dumpster area adjacent to the service hall during the annual recertification survey. The findings include: During the initial tour of the kitchen and the outside dumpster area of the facility on 3/9/2026 at 7:45 AM the surveyor with the Food Services Director (FSD) and District Manager in attendance observed the outside dumpster area. There were 2 trash dumpsters outside. One of the trash dumpsters did not have the attached lid closed on the dumpster. In an interview with the FSD on 3/9/2026 the surveyor asked what the expectation was for the lid being closed on the trash dumpster. The FSD stated that the dumpster should have the lid closed. The FSD closed the lid to the trash dumpster. At 2:10 PM on 3/11/2026 the surveyor observed that the door to one of the trash dumpsters outside the facility was opened. There were no staff in attendance 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 observations and facility staff interviews it was determined that the facility failed to have call lights accessible for Residents. This finding was found to be evident in 2 (Resident #18 and Resident #75) out of 28 Residents reviewed for accessibility of Resident Call System.The findings include:Resident Call System (or nurse call systems) are essential safety communication tools in nursing homes, enabling Residents and families to alert staff via push-button stations or pull cords. The call station is fixed units in rooms, bathrooms or common areasDuring tour of station 2 nursing unit on 3/9/2026 at 10:15 AM the surveyor observed the attached pull cord/string to the call light device panel next to the toilet in Resident #18's shared bathroom that was short in length. The call light device was not accessible to Resident #18 if he/she was on the floor. Resident #18 was not in his/her room or the bathroom.Additionally, on 3/9/2026 at 12:30 PM the surveyor observed that there was no pull cord/string attached to the call light device panel next to the toilet in Resident #75'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 observations and staff interviews, it was determined the facility failed to provide a resident with an environment that promotes a dignified existence. This was evident for 1 (Resident #349) of 8 residents reviewed for dignity. The findings include: On 12/2/24 at 8:25 AM, an observation was made of Resident #349's room. A clear plastic bag was lining the commode. Inside the bag was a yellow-colored liquid with a piece of toilet paper inside. This Surveyor took a picture of the commode. On 12/2/24 at 8:27 AM, an interview was conducted with Registered Nurse (RN) #3. When asked why the resident had a plastic bag over the commode, RN #3 stated they were not sure but stated that the resident does things their way. On 12/3/24 at 10:30 AM, an interview was conducted with RN #7. When asked why there was a bag over the commode, the nurse stated they used bags to dispose of the waste when Resident #349 had a stomach infection recently and kept using a plastic bag to line the commode even after the resident was cleared from the infection.

Based on observations and staff interviews, it was determined that the facility failed to ensure the call bells were within reach of a resident. This was evident in 1 (Resident #79) of 1 resident reviewed for access to the call system during the recertification survey. The findings include: On 12/2/2024 at 8:33 AM, Resident #79's call bell was observed by surveyors on the floor next to their bed. Further observation on 12/4/2024 at 8:36 AM again revealed Resident #79's call bell on the floor. Geriatric Nursing Assistant (GNA) #11 was interviewed by surveyors on 12/4/2024 at 8:40 AM. GNA #11 confirmed the call bell was on the floor and picked up the call bell and placed it next to the resident. Resident #79's call bell was observed by surveyors on 12/5/2024 at 8:58 AM to be on the floor behind their bed. Licensed Practical Nurse (LPN) #15 was interviewed at 8:59 AM and stated expectations that the call bell is always within reach of the resident. LPN #15 then picked up the call bell and placed it next to the resident. LPN #15 further stated that there was no clip for the call bell…

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, it was determined that the facility staff failed: (1.) to provide documentation whether a Resident had an advance directive and/or wished to formulate an advance directive and (2.) to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) in place. This was found to be evident for 2 (Resident #32 and #23) out of 12 residents reviewed for the MOLST and advance directives. The findings include: 1. The surveyor observed Resident #32 on 12/2/2024 at 9:45 AM in bed. Resident #32 was alert and oriented to person, place and time. On 12/3/2024 at 2:00 PM the surveyor conducted a record review of Resident #32's medical record. Resident #32 was admitted to the facility on [DATE]. An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if you are unable to do so yourself. During the record review of Resident #32's medical record it revealed that…

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 and staff interview during facility environmental observations, it was determined that the facility staff (1.) failed to provide housekeeping and maintenance services necessary to maintain a safe homelike interior and (2.) failed to exercise reasonable care for the protection of the resident's property from the wandering residents. This was evident for 1 of 8 rooms and 1 (Resident #67) out of 3 residents observed during the annual survey. The findings include: 1a. On 12/2/24 at 1 PM surveyors conducted an environmental tour which revealed: - room [ROOM NUMBER]: the baseboard on the wall adjacent to the resident's closet had visible damage- jagged edges where pieces of the baseboard were missing. - Circular shaped brown stains on two ceiling tiles in the shower room on the 200 unit One of the stained areas measured 6 inches in diameter and the other area measured 2 inches in diameter. - A structural wall to the left upon entrance into the shower room on the 200 unit with two capped copper…

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, it was determined that the facility staff failed to provide a safe resident environment and protect residents from abuse from other residents. This was found to be evident for 2 (Resident #22 [1.] and #113 [2.]) out of 9 residents reviewed for abuse. The findings included: 1. Record review, on 12/05/24 at 9:05 AM, found that staff GNA #30 witnessed Resident #103 on 4/14/23 at 4:30 PM that Resident #103 undressed while standing at Resident #22's bed side and had his/her hands in Resident #22's private area on. Immediately, GNA #30 called LPN staff #31 to assist and they removed Resident #103 out of Resident #22's room and started the one-to-one supervision. Additionally, they notified the local police about the abuse. No other residents were affected after the facility staff done the investigation. Resident #103 was arrested by the local police that night and had not returned to the facility since. During Interview, on 12/5/2024 at 09:55 AM, the Administrator stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interviews it was determined the facility failed to provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 2 (Resident #54 [1.] and #34 [2.]) of 6 residents reviewed for hospitalization. The findings include: 1. On 12/3/24 at 1:53 PM, the surveyor reviewed Resident #54's medical record. The review revealed that resident #54 was sent to the hospital on [DATE]. On 12/4/24 at 12:24 AM, the surveyor reviewed the transfer documents that were sent to the hospital. A bed hold was filled out on 12/1/24 by Unit Manager Staff #15 indicating that Resident #54 wanted a bed hold. There was no indication on the form that the resident and/or representative was informed or contacted to place the bed hold. On 12/4/24 at 12:57 PM, the surveyor conducted an interview with Staff #15 and the Director of Nursing (DON). During the interview Staff #15 reported that she initiated the bed hold…

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, facility staff interview and medical record review, it was determined that the facility failed to accurately document resident assessments on the MDS (Minimum Data Set) as evidenced by inaccurate coding for residents. This was found to be evident for 2 (Resident #42 [1.] and #79 [2.]) out of 2 residents reviewed for accuracy of MDS assessments. The findings include: 1. A colostomy is a surgical procedure that creates an opening in the colon (large intestine). The opening is called a stoma. A bag called a stoma appliance is placed around the opening to allow stool to drain. On 12/2/2024 at 10:45 AM the surveyor observed Resident #42 in bed in the resident's room. The resident was observed with a colostomy bag on the abdomen. The surveyor interviewed Registered Nurse (RN) Unit Manager #8 on 12/5/2024 at 10:15 AM. The surveyor asked the RN, Unit Manager #8, if Resident #42 had a colostomy and if Resident #42 was admitted to the facility with a colostomy. The RN Unit Manager #8 stated that…

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 staff interview, it was determined that the facility failed to initiate a new pre-admission screening and resident review (PASARR) Level I screen after a resident was diagnosed with bipolar disorder while admitted to nursing facility. This was identified for 1 (Resident #49) of 1 resident reviewed for PASARR requirements during an recertification survey. The findings include: According to the State Operations Manual, The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities and related conditions. This initial screening is referred to as Level I Identification of individuals with mental disorder (MI) or intellectual disorder (ID), and is completed prior to admission to a nursing facility. The purpose of the Level I pre-admission screening is to identify individuals who have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation 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 record review and interviews, it was determined that the facility failed to include all initial healthcare information in the baseline care plan. This was found evident of 1 (resident #94) of 5 residents reviewed for care planning. The findings include: On 12/5/24 at 10:04 AM, the surveyor reviewed Resident #94's medical record. The review revealed that Resident #94 was admitted to the facility on [DATE]rd 2024. Further review revealed that Resident #94 had a past medical history that included, but not limited to, congestive heart failure, atrial fibrillation (abnormal heart rhythm), malaise (weakness) disease of the digestive system and dementia. Next the surveyor reviewed Resident #94's care plan. Care plan topics were first initiated on 10/3/24 and included activities of daily living, risk for pain and risk for falls. On 10/4/24 additional care plans were added to include the need for enhanced barrier precautions, risk for bleeding, congestive heart failure, hypertension (high blood pressure)/atrial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility failed to develop a comprehensive person-centered care plan. This was found to be evident of 3 (Resident #94 [1.], #77 [2.] & #42 [3.]) of 13 Residents reviewed for care planning. The findings include: 1. On 12/5/24 at 10:04 AM, the surveyor reviewed Resident #94's medical record. The review revealed that Resident #94 was admitted to the facility in October of 2024. Further review revealed that Resident #94 had a past medical history of urinary retention and malaise (weakness). On 12/5/24 at 11:16 AM, the surveyor observed Resident #94 resting in bed with a urinary bag hanging on the side of the bed. Next the surveyor reviewed Resident #94's care plan. No care plan was noted for an indwelling urinary device. On further review a care plan for Activities of Daily Living (ADLs ) that was initiated on 10/3/24 indicated that Resident #94 was dependent, needing substantial/maximal assistance, and totally dependent for hygiene, shower/bath, lower…

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 and medical record review it was determined that the facility failed to update and revise resident's care plans. This was found to be evident in 1 (Resident #42) out of 3 residents reviewed for care plan timing and revision. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems of residents. Apixaban (brand name Eliquis) is a prescription anticoagulant medication that helps prevent and treat blood clots. It works by inhibiting factor Xa, a clotting factor, which slows blood clotting. Clonazepam (brand name Klonopin) is a prescription benzodiazepine medication used to prevent and treat anxiety disorders and seizures and promote relaxation. Clonazepam produces a calming effect on the brain and nerves. On 12/5/2024 at 8:30 AM…

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, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent residents. This was found evident in 2 (Resident #449[1.] & #68[2.]) out of 11 Residents reviewed for Activity of Daily Living (ADL) cares. The findings include: 1. On 12/2/24 at 2:13 PM, the surveyor interviewed Resident #449. During the interview Resident #449 stated that he/she had concerns about ostomy (a surgical procedure that creates an opening in the abdominal wall to allow waste to exit the body) cares. On 12/5/24 at 11:08 AM, the surveyor reviewed Resident #449's medical record. The review revealed that Resident #449 had a care plan initiated on 11/18/24 that stated, Resident #449 has an alteration in bowel elimination related to need for ileostomy (an ostomy in which the opening is the end of the ileum, the lowest part of the small intestine). An intervention listed was, provide assistance with ostomy care as needed. On further review a Minimum Data Set (MDS) assessment, that was completed on 10/20/24, documented…

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, interviews, and record review, it was determined that the facility failed to provide treatments according to a resident's plan of care. This was found evident of 2 (Resident #71 & #94) out of 32 residents reviewed during the survey. The findings include: 1a) On 12/2/24 at 10:12 AM, the surveyor interviewed Resident #71. During the interview Resident #71 stated that he/she had problems with constipation. Resident #71 further stated that he/she was given Miralax (a medication used to prevent and treat constipation) but still could go 2-3 days without having a bowel movement. On 12/5/24 at 8:43 AM, the surveyor reviewed Resident #71's medical record. The review revealed Resident #71 had a care plan initiated on 3/28/23 that stated Resident #71 is at risk for constipation related to decreased mobility. An intervention listed was to administer medications per medical provider's order. On further review the surveyor noted a progress note written by Nurse Practitioner (NP) Staff #22 written on 9/19/24. The note stated that Resident #71 complained of occasional hard…

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 resident interview, record review, and staff interview, it was determined that the facility failed to ensure to coordinate vision services for a resident. This was evident for 1 (Resident #77) of 8 residents reviewed for vision. The findings include: On 12/02/24 at 11:20 AM, an observation and interview of Resident #77 was conducted. It was noted that the resident had one lens on the left side of their glasses and no lens on the other side. When asked how long ago the resident had lost their lens, the resident stated it was months ago at the facility. The resident stated they let the staff know their lens fell out, but there was never any follow up. When asked if they knew when their last ophthalmologist appointment was, the resident stated they had not seen an ophthalmologist since admission to the facility. On 12/05/24 at 10:04 AM, Resident #77's records were reviewed. A consult for Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed was ordered on 6/20/2024 at 17:04 (5:04 PM) . 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 record review and interview, it was determined that the facility failed to protect the resident from a preventable accidents. This was evident for 1 (Resident #104) of 3 residents reviewed for falls. The findings include: On 12/06/24 at 10:17 AM, a review of complaint #MD00200713 was conducted. The complaint indicates that on 12/10/23, Resident #104 fell off the bed while a Geriatric Nursing Assistant (GNA) was providing incontinent care. After the providers evaluation the provider recommended to monitor and manage the resident for pain. The resident and family decided to call 911 to get further evaluation. On 12/06/24 at 10:22 AM, a review of Resident #104's records was conducted. The records indicated that the resident was evaluated at hospital for possible injuries after a fall on 12/10/23. Per hospital discharge summary, there were no injuries or fractures identified after x-rays and evaluation. On 12/6/24 at 10:45 AM, Resident #104's Multiple Data Set (MDS) was reviewed. An MDS is a federally mandated assessment tool used in nursing homes to evaluate the health needs…

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 resident observation, staff interview and record review it was determined that the facility failed to provide adequate care and services for a resident that required colostomy care. This was found to be evident in 1 Resident #42 out of 1 Resident reviewed for colostomy care and services. The findings include: A colostomy is a surgical procedure that creates an opening in the colon (large intestine). The opening is called a stoma. A bag called a stoma appliance is placed around the opening to allow stool to drain. On 12/2/2024 at 10:45 AM the surveyor observed Resident #42 in bed in Resident room. The resident was observed with a colostomy bag on the abdomen. The surveyor conducted a record review of Resident #42's medical record on 12/5/2024 at 8:30 AM. The medical record review, specifically the physician orders, revealed that Resident #42 did not have a physician order for the care of the colostomy. The surveyor interviewed Registered Nurse (RN) Unit Manager #8 on 12/5/2024 at 10:15 AM. 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, interview and medical record review it was determined that the facility failed to provide respiratory care and services appropriately. This was found to be evident for 1 (Resident #21) out of 1 resident that was reviewed for respiratory care and services. The findings include: On 12/2/2024 at 10:35 AM the surveyor conducted a tour of Unit 200 and observed Resident #21 in the resident's room with oxygen in use. The surveyor observed that Resident #21 did not have an oxygen in use - no smoking signage on Resident #21's door to the resident's room. The Medication/Treatment Administration Record (MAR/TAR) is a standardized record that organizes essential information about a resident and the prescribed medication and treatment. This vital document supports healthcare providers by tracking doses, preventing errors, and providing a clear record of care. The surveyor conducted a record review on 12/4/2024 at 7:30 AM of Resident #21's medical record. This record review revealed that Resident #21 had a physician order for continuous oxygen and had a care plan…

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, record review and observation, it was determined that the facility staff failed to ensure that pain management of an intrathecal baclofen pump was provided to residents who require such services, consistent with professional standards of practice and monitoring appropriately for effectiveness and/or adverse consequences. This was found to be evident for 1 resident (#22) out of 1 for pain management review. The findings included: A baclofen pump is a surgically implanted device that delivers baclofen, a muscle relaxant medication, directly into the spinal canal to treat spasticity and other conditions. The pump's battery typically lasts around six to seven years. When the battery dies, the pump needs to be replaced with a surgical procedure. The pump needs to be refilled regularly, usually every four to six months. A needle is inserted through the skin into the refill port to add baclofen. Complications can occur, including catheter disconnections, migration, kinks, obstruction, and pump…

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

Based on record review and interviews it was determined that the facility failed to have the medical provider thoroughly review and accurately document a resident's updated plan of care after a visit. This was found evident of 1 (Resident #106) out of 32 reviewed during the survey. The findings include: On 12/11/24 at 6:31 AM, the surveyor reviewed Resident #106's medical record. The review revealed that Resident #106 was admitted to the facility in late March of 2024 and was sent to the hospital in early April 2024 related to mental status changes, hypotension (low blood pressure), tachycardia (high heart rate) and increased creatinine and white blood cell count. Resident #106 returned to the facility with a Percutaneous Endoscopic Gastrostomy (PEG) tube or feeding tube related to his/her dysphagia (difficulty swallowing). After two days back at the facility Resident #106 then returned to the hospital due to a dislodged PEG tube and came back to the facility on 5/1/24 with a new tube placed. Next the surveyor reviewed Resident #106's orders. The review revealed Resident #106 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 medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs. This was evident for 2 (Resident #94 and #106) or 7 residents reviewed for unnecessary medications. The findings include: 1a) On 12/5/24 at 10:04 AM, the surveyor reviewed Resident #94's medical record. The review revealed that Resident #94 was admitted to the facility in October of 2024. Further review revealed a progress note written by Nurse Practitioner (NP) Staff #23 on 12/4/24 related to Resident #94's abnormal lab values. Staff #23 documented Resident #94 had a low sodium and magnesium lab. The note further stated that she collaborated with the attending and a new order for sodium chloride 2 grams would be written and magnesium oxide 400 milligrams would be increased to two tables twice a day. On 12/6/24 at 7:25 AM, the surveyor reviewed Resident #94's December Medication Administration Record (MAR). The review revealed that Resident #94 had an order that started on 11/26/24 for sodium chloride 1…

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 resident records, it was determined that the facility failed to coordinate routine dental services for a resident. It was evident for 1 (Resident #68) of 8 residents reviewed for dental services. The findings include: On 12/03/24 at 9:30 AM, an interview was conducted with Resident #68's representative. The representative stated that on 10/28/24 they visited the resident, and upon their observation the resident's teeth were black. On 12/03/24 at 9:45 AM, Complaint #MD00211334 was reviewed. This complaint expressed concerns with Resident #68's dental care and appointments. On 12/04/24 at 10:40 AM, a review of Resident #68's orders was conducted. An order for a dental consult was made on 8/28/23. On 12/04/24 at 1:52 PM, a review of resident records was conducted. The resident was last seen by the Dental Group on 10/30/23. On the dental note of 10/30/23, the recommendation for the resident was to be seen every 6 months for cleaning with a next annual appointment date of 10/30/24. On 12/04/24 at 1:55 PM, an interview was conducted with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, it was determined that the facility failed to keep accurate resident records in accordance with professional standards. This was evident of 1 (Resident #54) out of 32 residents reviewed for accuracy of documentation during the survey. The findings include: On 12/3/24 at 1:53 PM, the surveyor reviewed Resident #54 ' s medical record. The review revealed that Resident #54 was sent to the hospital on [DATE]. Next the surveyor reviewed the transfer form for Resident #54 dated 12/1/24. The review revealed in the dedicated section titled; Resident Representative Notification, the date and time of 12/1/24 at 12 PM were there, however, the name of the representative was left blank. On 12/4/24 at 12:54 PM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #27. The surveyor asked Staff #27 if she notified Resident #54's representative of the transfer to the hospital. Staff #27 stated she notified Resident #54's representative however, she didn't lock the note until…

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 staff interviews, it was determined that the facility failed to follow proper infection control practices when handling a resident's waste. This was evident for 1 (Resident #349) of 8 residents reviewed for infection control. The findings include: On 12/2/24 at 8:25 AM, an observation was made of Resident #349's room. A clear plastic bag was lining the commode. Inside the bag was a yellow-colored liquid with a piece of toilet paper inside. This Surveyor took a picture of the commode. On 12/2/24 at 8:27 AM, an interview was conducted with Registered Nurse (RN) #3. When asked why the resident had a plastic bag over the commode, RN #3 stated they were not sure but stated that the resident does things their way. On 12/3/24 at 10:30 AM, an interview was conducted with RN #7. When asked why there was a bag over the commode, the nurse stated they used bags to dispose of the waste when Resident #349 had a stomach infection recently and kept using the plastic bag even after the resident was cleared from the infection. When asked how the waste was disposed of, he…

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 clinical record review and staff interview, it was determined that the facility failed to notify and obtain consent from a resident representative for immunizations. This was evident for 1 (Resident #92) of 5 residents reviewed for immunizations during recertification survey. The findings include: Brief Interview for Mental Status (BIMS) is an assessment tool used to identify cognitive impairment in long-term care facilities and nursing homes. It's a mandatory tool for new residents and is also used regularly to track a resident's cognitive functioning over time. The BIMS score ranges from 0-15, with higher scores indicating better cognitive functioning. The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Resident #92's medical records were…

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, review of facility pest control records and interviews of facility staff, it was determined the facility failed to ensure an effective pest control program as flying gnats were observed throughout the building. This was found to be evident during the survey. The findings include: On 12/02/24 at 9 AM, during a tour of the 200 unit, surveyors observed gnats in room [ROOM NUMBER]'s toilet room. On 12/02/24 at 12 noon, surveyors were standing near the entrance of room [ROOM NUMBER] and observed gnats flying near their faces. On 12/03/24 at 9 AM surveyors interviewed, the Food Service Director, Staff #6, who confirmed that the kitchen had gnats by the floor drains and the juice machine. In addition, Staff #6 stated that the maintenance department was contacted at that time to address the issue. On 12/03/24 at 11:30 AM surveyors conducted a review of all maintenance records for room [ROOM NUMBER] which did not reveal any pest control visits or maintenance interventions for gnats. Further review…

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 observation it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect all residents. The findings include: On 10/29/2019 an environmental tour of the facility was conducted as part of the survey process and in regards to complaint MD00140781. At 9:47 AM observation of room [ROOM NUMBER] revealed broken ceiling tiles in the bathroom around the air vent and cove molding which was separating from the wall beneath the toilet paper holder. A pair of sweatpants was observed draped over the handicap assist bars in the bathroom approximately 1 foot from the open toilet. At 10:42 AM room [ROOM NUMBER] was observed with missing cove molding behind the toilet and exposed drywall on the wall near the floor. Additionally at 10:42 AM the air intake vent opposite Nurse Station 1 was observed with excess grey dust and debris. The Station 2 Spa Room was inspected at 11:51 AM revealing pink and black buildup 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 medical records review, and resident and staff interview it was determined that the facility staff failed to notify the physician that the resident missed their scheduled Nephrologist (Kidney physician) appointment. This was true for 1 of 45 residents (Resident #33) reviewed for notification during the complaint survey. The findings include: During an interview with Resident #33 on 10/25/19 at 1:30 PM the resident revealed that he/she was upset because the facility messed up with transportation and that he/she missed the kidney doctor appointment. On 10/29/19 at 12:00 PM Resident #33's medical records were reviewed. This review revealed that the resident was admitted to the facility in May 2019 for rehabilitation and with diagnosis which included Chronic Kidney Disease stage 5. A person with stage 5 chronic kidney disease has end stage renal disease (ESRD). At this advanced stage of kidney disease, the kidneys have lost nearly all their ability to do their job effectively, and eventually dialysis or a kidney transplant is needed to live. Medical records reviewed 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 resident and staff interview and review of Facility Reports MD00145732 and MD00146337, it was determined that the facility failed to ensure residents were free from misappropriation of resident property and exploitation. This was evident for 2 of 45 residents (Resident #78 and Resident # 75) reviewed during the survey. The findings include: 1. On 10/28/2019 a review of the facility's investigation for facility report MD00145732 was conducted. The facility confirmed that a GNA #28 had taken a resident's (Resident #78) bank card and withdrawn $200. This GNA never repaid Resident #78. Interview with Resident #78 on 10/29/2019 at 10:42 AM confirmed that the bank card was lent to the GNA #28 with the understanding that the money withdrawn would be repaid. Further review of the facility's Employee Handbook revealed a section on Gratuities in which employees are instructed to never borrow money from a resident or his/her family members. Interview with the Administrator on 11/6/2019 at 11:06 AM confirmed that the GNA #28 was no longer employed by the facility and the incident had…

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 with the resident family and facility staff it was determined the facility failed to organize and invite the Resident and/or Responsible Party (RP) to a care plan conferences. This was found to be evident for 1 resident (Resident #34) reviewed for care plans during the survey. Findings include: An interview was conducted with the RP for Resident #34 on 10/25/19 at 2:05 PM to discuss concerns involving the resident. The RP stated that the facility has not contacted him/her in over a year regarding a care plan meeting. Review of the documentation provided by the facility revealed a letter dated 10/27/19 for a care plan meeting scheduled on 11/19/19 for Resident #34. The facility was unable to provide any other letters that were mailed inviting the RP to attend a care plan conference. An interview was conducted on 11/1/19 at 10:03 AM with the Social Work Director (SWD). The SWD stated that she started working for the facility June of 2019 and upon her arrival she was able to determine from her assessment that Long Term Care (LTC) had not…

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 review of resident medical records, review of facility investigative material, and interview with facility staff, it was determined that the facility failed to ensure that residents going outside were safe to do so without supervision. This was evident for 1 of 3 residents (Resident #189) reviewed for accidents. The findings include: Resident #189's medical record was reviewed on 10/28/19 at 12:00 PM. During the review, it was determined that the resident was admitted to the facility at the end of September 2018, and eloped 3 days after admission. The resident's admitting diagnoses included a recent stroke that the resident was hospitalized for and then transferred to the facility for rehabilitation. A screen for the resident's elopement risk was completed on the day of admission and indicated that the resident was not an elopement risk. Nursing assessments completed in the first three days of the resident's stay indicated that the resident was alert and oriented to self, but not to place or situation. Review of the facility's investigation regarding Resident #189'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 review of resident medical records and interview with residents and facility staff, it was determined that the facility failed to ensure that residents with as-needed pain medication regimens received pain medication according to physician prescribed parameters. This was evident for 1 of 4 residents (Resident #1) reviewed for Pain Management. The findings include: A numeric pain scale is a common tool to evaluate a resident's perception of his or her own pain. The resident is asked to rate pain from 0 (no pain) to 10 (worst pain of your life). The American Nurse's Association defines severe pain as number 7-10 on that scale. Other references include the numbers 6-10 as severe pain. Resident #1's medical record was reviewed on 10/28/2019 at 10:42 AM. During the review, it was noted that the resident was prescribed as-needed narcotic pain medication for severe pain. Resident #1's medication administration record (MAR) was reviewed for the duration of the resident's most recent stay. The review revealed that the resident was administered the as-needed narcotic pain 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.

Based on medical record review and interview with staff it was determined that the facility failed to notify the physician of abnormal laboratory results and failed to fax the results of the laboratory results to the kidney specialist. This was found to be evident for 1 of 45 residents (Resident #33) reviewed during the investigation stage of the survey. The findings include: On 10/30/19 Resident #33's medical records were reviewed. This review revealed a physician order to obtain an Intact PTH, phosphorus and 25 OH vitamin D and fax the laboratory results when they arrive. Review of the medical records revealed the results of the phosphorus and Vitamin D dated 8/30/19. Further review of the laboratory results failed to reveal any documentation indicating that the physician was aware of the results nor could the facility provide any documentation indicating that the results were faxed to the consulting office. During an interview with the Director of Nursing and the Unit Manager of Unit 2 RN #7 on 10/30/19 the surveyor asked for any documentation showing that the physician and 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 facility staff failed to maintain a medical record in the most accurate form for residents. This was evident for 2 of 45 residents (Resident #65 and #88) reviewed during the survey. 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. Records must be complete, accurately documented, readily accessible and systematically organized. 1. On 11/5/2019 at 9:54 AM Resident #65's monthly pharmacist assessments were reviewed. Resident #65 was found to have irregularities noted and/or recommendations made on 7/5, 7/10, 7/14, 8/12 and 8/14/2019 by the pharmacist. The electronic record showed that an irregularity was noted and/or recommendations were made however neither the electronic record nor the hard chart specified what the irregularities/recommendations were. At 10:41 AM the Director of Nursing (Staff #2) was asked 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.