Citizens Care And Rehabilitation Center Of Frederi

Based on observation, interview, and review of the facility policy, the facility failed to ensure all food in the freezer, refrigerator, and dry storage was labeled, dated, and not expired as well as failed to ensure newly washed dishes were allowed to properly air dry and staff wore the appropriate hair coverings. These failures had the potential to affect all 158 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Safety Product Labeling and Dating Guidelines, dated 12/06/22, revealed .Sodexo policy does not specify a date marking label. An establishment can choose to be as precise as needed in date marking if the parameters set forth within the Sodexo policy are met. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means to comply with policy and the food code . All managers and food employees need to be trained and understand the operation's date marking policy and the dating/labeling system they use . Review of the facility's policy titled, Hair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of facility policy, the facility failed to ensure expired insulin pens were discarded from five medication carts (respiratory care unit (RCU) cart two, second floor long-term care unit (LTC) medication carts one, second-floor LTC medication cart two, third floor LTC medication cart medication cart one, and memory care medication cart one) of nine medication carts reviewed. This failure placed residents at risk of ineffective medication. Findings included. Review of the facility policy titled, Medication Administration, dated [DATE] revealed, . Ensure that the open date is documented on the vial or pen .Check the expiration date prior to administration to ensure it is within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open date recorded should be discarded . 1. Review of RCU cart two on [DATE] at 3:35 PM with Licensed Practical Nurse (LPN)3 revealed, a Lantus (long-acting) insulin pen for R117 which had an…

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, record review, and review of facility policy, the facility failed to ensure infection control measures were appropriately implemented and maintained hand hygiene related to blood glucose testing for four of four residents (Resident (R) 35, R16, R77, and R14) who were observed during testing. Also, the facility failed to ensure wound care was performed in a manner to prevent infection for R115. These failures placed the residents at risk for infections and a decrease in quality of life. Findings include: 1. Review of the facility's policy titled, Glucometer Disinfection reviewed 10/14/24 indicated, Policy Explanation and Compliance Guidelines .5. Procedure: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands.e. Put on gloves. f. Obtain capillary blood glucose sampling according to facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. i. Retrieve a disinfectant wipe from container. j. Using wipe,…

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 review of the facility policy, the facility failed to ensure a Level II PASARR (a more in-depth preadmission screening and resident review) was obtained, as required for one resident (Resident (R)58) of three sampled residents in a total sample of 39. This failure placed the resident at risk of not receiving specialized services for serious mental illness. Findings included: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, dated 2024 revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening…

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, interview and facility policy review, the facility failed to develop a comprehensive care plan regarding a condom catheter for one of one resident (Resident (R)155) out of 39 sampled residents. This failure to develop a care plan increased the risk for care to be incomplete and/or inconsistent related to R155 having a condom catheter. Findings include: Review of R155's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R155 was admitted to the facility on [DATE] with diagnosis of chronic kidney failure, Stage 3, malignant neoplasm of the pancreas, chronic respiratory failure with dependence on ventilator, tracheostomy, and gastrostomy. Review of R155's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/11/24 coded the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R155 was moderately cognitively impaired. Review of R155'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to review and revise a comprehensive care plan to reflect the resolution developing of pressure ulcers and non-pressure wounds for one of four residents (Resident (R)155) out of 39 sampled residents. This failure created an increased risk for R155 to receive care and services not appropriate for their current clinical condition. Findings include: Review of R155's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R155 was admitted to the facility on [DATE] with diagnosis of malignant neoplasm of the pancreas, chronic respiratory failure with dependence on ventilator, tracheostomy, gastrostomy, pressure ulcer of other site, unstageable, pressure ulcer of other site, Stage 3, and non-pressure chronic ulcer of other part of right foot and left foot with fat exposed. Review of R155's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date…

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 facility policy review, the facility failed to accurately check the insulin pen that was being used to administer insulin to one of three resident (Resident (R) 14) administered insulin out of six residents being observed during the medication administration task. This failure had the potential for bloodborne pathogens to infect residents by using a reusable insulin pen to a resident other than the resident that it had been ordered for. Findings include: Review of the facility's policy titled Medication Administration .Insulin Administration dated 06/21/17 and provided by the facility stated, .Pens must be used only for a single resident and must never be shared . During an observation of medication administration on 12/16/24 at 4:50 PM, Licensed Practical Nurse (LPN)1 was observed in getting a new Novolog Insulin Pen from the Unit Manager (UM)3 which was obtained from the Cubex. LPN1 administered R77 with two units of Novolog insulin subcutaneously as ordered by the physician. LPN1 went to the next resident which was R14. LPN1 applied 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 interview, record review, and review of facility policy, the facility failed to ensure that the education of benefits and risks of immunizations for pneumonia and influenza was provided after refusals for the vaccinations for three residents (Residents (R) 36, R20, and R80) of five sampled residents reviewed for immunizations. This failure placed the residents at risk for pneumonia and influenza. Findings included: Review of facility policy titled, Pneumococcal Vaccine, dated 08/01/2024 revealed, .Prior to offering a pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record . Review of facility policy titled, Influenza Vaccination, dated 09/01/2024 revealed, . Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be offered a copy of CDC's (Center for Disease Control)…

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 physician failed to review orders for accuracy and failed to write, sign and date medical visit progress notes in resident medical records on the day that the resident was seen. This was evident for 1 (#2) of 11 residents reviewed in final sample and 1 (#6) of 3 residents reviewed for accidents 2 (#8, #9) of 3 residents reviewed. The findings include: 1) A record review on 9/10/19 at 10:00 AM, revealed physicians' order summaries dated 7/31/19 and 9/3/19, that documented 2 conflicting orders for oxygen therapy. Both orders were dated 7/3/19 and entered by Licensed Practical Nurse (LPN) #2, one order was for continuous oxygen through a nasal cannula (through the nose) at 2 liters of oxygen per minute and the second order was for oxygen 2 liters per minute through nasal cannula when his/her blood oxygen level is below 90%. Review of the physician's progress notes revealed that the attending physician noted on 7/5/19 and 7/22/19, I have reviewed the patient's current medications including medication names,…

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, a review of facility documentation and staff interview, it was determined that the facility failed to have a system in place to verify that staff had been educated to verify a resident's code status and Maryland Order for Life Sustaining Treatment (MOLST) prior to initiating or not preforming cardiopulmonary resuscitation (CPR). The findings include: Cardiopulmonary Resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. A DNR directive instructs health care providers not to perform (CPR) if a patient stops breathing or if their heart stops beating. The MOLST is a portable and enduring medical order form covering options for CPR and other life-sustaining treatments. Facility Reported Incident MD00140887 was reviewed on [DATE]. The Incident Report stated that, on [DATE], CPR (Cardio Pulmonary Resuscitation) was initiated on Resident # 43 and discontinued when it was determined that the resident had formulated a…

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 staff interview, it was determined that the facility failed to have a process in place to ensure that Geriatric Nursing Assistance were evaluated every 12 months to ensure competency. This was evident for 2 (#5 and #4) of 3 staff reviewed for competency. The findings include: 1) A record review for Geriatric Nursing Assistant (GNA) #5 on 9/11/19 at 2:00 PM, revealed that dementia training was completed on 8/25/17 and the GNA's next training was completed 16 months later on 12/1/18. In addition, the employee performance review was completed on 8/15/18 and 13 months later on 9/9/19. 2) A record review for GNA #4 on 9/11/19 at 2:10 PM, revealed they had a performance evaluation on 8/15/18 and 13 months later on 9/9/19. Director of Nursing and [NAME] President of Clinical Services were made aware of and acknowledged concerns on 9/12/19 at 9:05 AM.

Based on observation, resident interview, record review, and staff interview, it was determined that the facility staff failed to maintain accurate records for a resident's respiratory treatments. This was evident for 1 (#2) of 11 residents reviewed for care plans. The findings include: An observation of Resident #2 on 9/10/19 at 10:55 AM, revealed that the resident was not using continuous oxygen. During an interview with Resident #2 on 9/10/19 at 11:05 AM, he/she stated that they only wear the oxygen when feeling short of breath. A medical record review on 9/10/19 at 10:00 AM, revealed physicians' order summaries dated 7/31/19 and 9/3/19, that documented an order, dated 7/3/19, entered by Licensed Practical Nurse (LPN) #2, for continuous oxygen through a nasal cannula (through the nose) at 2 liters of oxygen per minute. An interview with Licensed Practical Nurse (LPN) #2 on 9/10/19 at 11:15, confirmed that the resident was not receiving continuous oxygen, but was being weaned. When shown the order for continuous oxygen and that she had signed it off for 9/10/19, she reported she…

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 facility staff failed to ensure that a resident received the assistance of two staff when providing care. This failure resulted in the resident's fall from bed, hematoma and transfer to the emergency room. This was evident for 1 of 5 residents (Resident # 162) reviewed for abuse during the survey. The findings include: Resident # 162's medical record was reviewed on 6/11/2019. The resident had relevant diagnoses of, but not limited to, persistent vegetative state and unspecified coma. Resident # 162 's Minimum Data Set (MDS) Assessment was evaluated on 6/11/2019. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Resident #162's MDS Assessment, with an Assessment Reference Date of 02/04/2019, was coded to reflect that the resident was totally dependent on the assistance of two staff members…

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 review of medical records and facility documentation, it was determined that the facility failed to 1). report allegations of abuse to the state survey agency timely and 2). ensure the timely reporting of a staff member's nonadherence to a resident's plan of care. This was found to be evident for 2 out of 8 facility reported incidents (FRI) reviewed during the annual survey regarding Resident # 151 and and Resident #162. The findings include: 1. Review of the FRI MD00134136 revealed an incident, an allegation of sexual abuse, that occurred on 11/24/18 regarding Resident #151. Further review of the facility investigation revealed that the incident was not reported to the state agency until 11/27/18. The Chief Nursing Officer (CNO) and the Director of Nursing (DON) were interviewed on 6/13/19 at 2:34 PM. The CNO stated that they were aware that it was a late report. The staff at the time documented the incident, but did not feel it should be reported. Once the CNO was notified and the DON found out about it, it was reported to the state agency. The CNO further…

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

Based on administrative record review, medical records review and interviews with facility staff, it was determined that the facility failed to 1). complete a thorough investigation when residents were noted to have an injury of unknown origin and 2). review staff interviews prior to terminating an investigation of a resident's unknown injury 3). implement corrective action to prevent further incidents of allegation of abuse from occurring. This was found to be evident for 4 (R #164, #111, #162 and #151)) of 7 intakes reviewed during the facility's annual Medicare/Medicaid survey. The findings include: 1. Intake # MD00137920 was reviewed on 6/5/ 19 for an injury of unknown origin. Review of the facility's investigation for an unknown injury for resident # 164 revealed that the resident was noted to have a raised hematoma bruise to the left forehead and a small bruise to the right side of the lip. Review of the medical records revealed that the resident was re-admitted to the facility in December 2017 for long term care and with diagnoses which included dementia with behavioral…

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 facility staff, it was determined that the facility failed to develop a person-centered individualized comprehensive care plan as evidenced by failure to develop a care plan to address resident activities, for 1 out of 38 (R #8) residents reviewed during the investigation stage of the long-term care survey process. 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. On 6/17/19, Resident # 8's medical records were reviewed and revealed that the resident was readmitted to the facility in April 2018 for long term care, with diagnoses that included Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and high blood pressure. Further review of the medical record revealed that, at one time, Resident #8 spoke both English and Spanish, but at the time of the survey, the resident spoke Spanish…

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 and staff, it was determined that the facility staff failed to 1). follow the interventions on the care plan to prevent skin break down, 2). to ensure that residents and responsible parties (RP) were included in the development and review of a resident's care plan and 3). update a resident's care plan related to reported allegations of sexual misconduct This was true for 3 of 38 (#93, #136 and #151) residents reviewed during the investigative stage of the survey. 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. 1. On 6/11/19, Resident # 93's medical records were reviewed and it was revealed that the resident was admitted to the facility in August 2018 with diagnoses which included: weakness, dementia and abnormalities of gait and mobility. Review of the wound nurse documentation revealed documentation that, on 10/16/18, the resident developed a facility acquired pressure ulcer caused 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview with facility staff, it was determined that the facility failed to1) provide activities for an individual based on their assessment, cultural needs, and language/communication and 1a) ensure residents were given an opportunity to attend activities. This was evident for 3 (Resident # 136, # 8 and #126) of 4 residents reviewed for activities in the investigative stage of the survey. The findings include: 1). Resident #136 was observed on their unit on [DATE], [DATE], and [DATE]. During the observations, the resident was not seen in activities. An interview was attempted with the resident on [DATE] at 9:55 AM, however, it appeared that the resident was unable to comprehend the surveyor's questions. An activity on the unit was conducted on [DATE] at 10:10AM. The resident was observed in the room where an activity was being conducted, but did not engage with the participants. Review of the medical record of Resident # 136 was conducted on [DATE] at 12:16…

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 administrative record review and interviews with facility staff, it was determined that the facility failed to have a nurse assess a resident when the resident complained of pain during toileting by a GNA. This was found to be evident for 1 (Resident #111) of 6 intakes reviewed during the facility's annual Medicare/Medicaid survey. Findings include: Intake # MD00130624 was reviewed on 6/5/ 19 for injury of unknown origin. Upon review of the facility's investigation, resident # 111 was noted to have a bruise to the left upper arm. The facility ordered an x-ray of the left shoulder. According to the investigation, the resident c/o pain when the nurse attempted to transfer the resident from the wheelchair to the bed so that the x-ray could be obtained. The x-ray results showed a finding of left shoulder and hip fracture. Resident # 111 was admitted to the facility with the following but not limited diagnoses: Osteoarthritis of Knee, Vitamin D Deficiency, Age Related Osteoporosis and Unsteadiness on Feet. An interview was conducted with GNA, staff # 8 on 6/11/19 at 12:10 PM 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 interview with facility staff, it was determined that the facility failed to follow up on a recommendation from the physician for an ophthalmology visit. This was evident during the review of 1 of 38(R#98) resident medical records reviewed during the investigative process. The findings include: During the initial tour, on 6/5/19 at 10:54 AM, the surveyor attempted to interview Resident #98. S/he stated that s/he was not feeling that well and the interview was postponed to a later date. On 6/7/19 at 8:58 AM, Resident #98's medical record was reviewed. His/her diagnosis was noted to include a history of pneumonia, muscle weakness and a need for assistance with personal care. Review of the physician's progress note, completed on 3/18/19, documented that the resident had a vision deficit and will see an ophthalmologist. Further review of the medical record failed to reveal a referral to an ophthalmologist. The DON and Chief Nursing Officer (CNO) were notified of the concern and physician's note found in Resident #98's medical record on 6/11/19. On…

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

Based on medical record review and staff interview, it was determined the facility staff failed to prevent the development of a pressure ulcers for a functionally impaired resident (Resident #93). This was evident for 2 of 8 residents reviewed for pressure ulcer during the investigative stage of the survey. A pressure ulcer also known as bed sore or decubitus ulcer is any lesion caused by unrelieved pressure or shearing that results in damage to the skin and underlying tissue. Pressure ulcers are staged according to the severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). Pressure is one of the main causes of a decubitus ulcer. Lying on a certain part of your body for long periods may cause your skin to break down. The findings include: On 6/11/19, Resident # 93's medical records were reviewed. This 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.

1) a During the initial tour on 6/5/19 at 10:54 AM, surveyor attempted to interview Resident #98 regarding FRI MD00134526. S/he stated that s/he was not feeling that well, but did recall the incident and would like to discuss it further at another time. On 6/7/19 at 8:58 AM, Resident #98's medical record was reviewed. His/her diagnoses included a history of pneumonia, muscle weakness and a need for assistance with personal care. A review of the resident's most recent BIMS showed the resident scored at a 15, (13-15 result is cognitively intact). A review of the FRI noted that, on 12/13/18, Resident #98 reported to the day shift Unit manager that Staff # 7 (from the previous shift) had thrown the call light and hit him/her in the eye. The resident was assessed and noted to have a swollen and red/bruised area to the crease of the right eye. The Resident further noted that, when it occurred s/he had cried out loudly and Staff # 7 just walked out of the room. Administration viewed the camera footage and found that Staff # 7, who was assigned to care for the resident, was the only…

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.