Anchorage Rehabilitation and Wellness Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to: 1.) Maintain and provide documentation of required Ombudsman notifications related to resident transfers and discharges and provide the resident and/or resident representative with written notification of transfer to the hospital and written notification of the facility's bed hold policy. This is evident for 4 (Residents #2, #11, #110, and #112) of 7 residents reviewed for transfers and discharge. The findings include: Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1. On 12/8/25 at 10:19 AM, a request was made for documentation showing the facility's notification to the Ombudsman regarding the October 2025 hospitalizations of Residents #2 and #11. At 3:08 PM the same day, the documentation was again requested from Staff #3. On 12/9/25 at 7:56 AM, during an interview, Staff #3 stated the facility was unable to produce the required…

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 with staff, it was determined that the facility failed to provide the resident and/or resident representative with a written summary of their baseline care plan. This was evident for 2 residents (Resident #110 and #112) out of 41 residents reviewed during the annual survey.The findings include: 1. On 12/9/2025 at 10:31AM, the Surveyor discovered that Resident #112 was admitted to the facility on [DATE] from the hospital for hyperglycemic management and physical and occupational therapy. A review of the resident's electronic medical record revealed a care conference sign in sheet dated 9/5/2025 where resident representatives, Social Worker (SW) #11, and the Director of Rehabilitation (DOR) #20 were in attendance. Additional review failed to reveal documentation that the resident and/or resident representatives received a copy of the written summary of their baseline care plan.2. On 12/9/2025 at 11:21AM, during a review of Resident #110's electronic medical record, 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 record review and interviews with staff, it was determined that the facility failed to ensure comprehensive person-centered care plans were developed and implemented for residents. This was evident for 2 (Resident #111 and Resident #112) out 41 residents reviewed during the annual survey.The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.Palliative care is specialized medical care for people living with a serious illness and is focused on providing relief from symptoms and stress of the illness. The goal is to improve the quality of life for both the patient and the family. Maryland Medical Orders for…

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 with residents and staff, it was determined that the facility failed to 1.) Have a system in place to ensure the resident and/or resident representative had the opportunity to participate in their care planning process with members of the interdisciplinary team at care plan meetings. 2.) Hold and complete quarterly care plan meetings for residents an 3.) Perform appropriate revisions to resident's care plans. This was evident for 4 (Resident #112, #110, #6 and #89) out of 41 residents reviewed during the annual survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments. It outlines what needs to be done to plan, assess, and manage care needs. This helps to evaluate the effectiveness of the resident's care. The residents, their family or legal representative, and the nursing home interdisciplinary team must participate in the residents' care plan meetings. The interdisciplinary team (IDT) includes…

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

Based on observation and interview it was determined that the facility failed to maintain a resident environment that is free of accident hazards. This was evident for 2 out of 4 housekeeping carts observed during the annual survey. The findings include : During observation rounds on 12/04/2025 at 8:30 AM housekeeping cart on facility ground level was found to be unattended and unlocked containing containers of cleaning chemicals. During observation rounds on 12/08/2025 at 8:45 AM housekeeping cart on facility second floor was found to be unattended and unlocked containing containers of cleaning chemicals. During interview on 12/08/2025 at 1:00 PM staff #13 stated and confirmed, both housekeeping carts are unlocked due to the locks being broken. Staff #13 further stated, all housekeeping carts should be locked at all times to prevent the residents from getting into them, new locks will be ordered and carts will be kept locked up in a room until new locks arrive.

Based on observation, interview, and record review it was determined the facility failed to follow medical orders for respiratory care consistent with professional standards of care. This was evident for 1 (#3) out of 2 Residents reviewed for respiratory during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility, the surveyor observed Resident #3 on 12/4/25 at 7:43AM receiving oxygen delivered to their tracheostomy in which the plastic tubing for the system was observed to have an unclean appearance with an orange and brown crusted appearing substance and debris present which was also observed to be present on Resident #3's hospital gown they were wearing. Further observation of the respiratory equipment at this time revealed Resident #3's humidification bottle attached to the oxygen delivery system was empty and dry in appearance, and not providing any humidification to the resident while oxygen was being delivered via a concentrator observed to be set at 8 liters per minute. On 12/4/25 at 7:43AM the surveyor conducted 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 and record review it was determined the facility failed to ensure adequate staffing level to meet the needs of residents on the facility's second floor. This was evident for 1 (floor #2) out of 3 floors of the facility during the surveyor's initial tour. The findings include:During an interview of Licensed Practical Nurse (LPN) #17 on 12/4/25 at 7:50AM conducted by the surveyor, LPN #17 confirmed the second floor Unit Manager #18 was not here yet. On 12/4/25 at 8:26AM the surveyor observed the posted staffing on the board located near the nurse's station on the facility's second floor at which time it was noted that the staffing consisted of LPN #17, two Geriatric Nursing Assistants (GNA), and Unit Manager #18 for the 12/4/25 7am-7pm shift. On 12/4/25 at 7:39AM two urinals containing yellow liquid were observed by the surveyor on Resident #28's over bed table sitting next to their drinking water. On 12/4/25 at 7:55AM the surveyor shared the concern and conducted an interview with GNA #9. GNA #9 stated to the surveyor: Okay, I'll take care of it, I'm…

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

Based on record review and interview it was determined facility staff failed to ensure documentation of attempts made to offer advanced directives. This was evident for 1 (#43) out of 5 Residents reviewed for advanced directives during the facility's recertification survey. The findings include: Review of the medical record of Resident #43 by the surveyor on 12/4/25 at 4:56PM revealed there was no documentation able to be found regarding documentation of advance directives offered. Review of the facility's general admission packet revealed that advance directive information offered to Residents of the facility was contained within the packet. On 12/5/25 at 10:41AM the surveyor conducted an interview of the facility's Administrator at which time they reported that Staff #11 was the facility's Social Worker for the past six months. At this time the surveyor requested an interview of the facility Social Worker. On 12/5/25 at 10:45AM the surveyor conducted an interview of the facility's Director of Social Work (DSW) #11 who reported that they offer advance directives to residents upon…

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 a review of a complaint, record review and interview, it was determined that the facility failed to notify the Physician and the Resident representative of a change in condition and an incident that potentially required a Physician intervention. This was evident for 1 (Resident #1) of 33 residents reviewed during the complaint survey.The facility implemented effective and thorough corrective measures following the change in condition and this incident prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be Past Noncompliance with a compliance date of 2/12/25The findings include: On 11/5/25 at 7:23 AM, a review of a Complaint #324972 indicated concerns with regard to family notification, neglect and unexpected death of the resident. A review of Resident #1's medical records revealed that on 1/3/15, Resident #1 had an abnormally high [NAME] Blood Cell count (WBC). A WBC count measures the number of these cells in the blood, which are important for fighting infection and disease. The test…

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 a review of a complaint, record review, and interview, it was determined that the facility failed to address an abnormal laboratory result and monitor a resident for signs of aspiration following an incident that potentially required a Physician intervention. This was evident for 1 (Resident #1) of 33 residents reviewed during the complaint survey.The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be Past Noncompliance with a compliance date of 2/12/25. The findings include:On 11/5/25 at 7:23 AM, a review of Complaint #324972 indicated concerns regarding neglect and unexpected death of the resident. A review of Resident #1's medical record revealed that on 1/3/15, Resident #1 had an abnormally high [NAME] Blood Cell count (WBC). A WBC count measures the number of these cells in the blood, which are important for fighting infection and disease. The test helps diagnose or monitor conditions like…

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

Based on observation and interview it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident throughout the facility and for seven (Resident #17, #21, #82, #10, #2, #15 and #19) out of 43 residents reviewed during the survey. The findings include: 1) On 3/17/24 at 1:35 PM, an initial tour of the dry storage area of the kitchen revealed a puddle of standing water on the floor underneath and in front of one of the dry storage racks. There was also damaged floor tiles and at least two damaged baseboard tiles. The back wall of the the dry storage area was observed to be discolored and the corner of the room had black stains from the floor to ceiling. On 3/21/24 at 12:04 PM, surveyor reviewed observations made on 3/17 with the Food Service Director (FSD Staff #8). The FSD reported the damaged floor tiles had been reported to maintenance since they started at the facility, which was more than one year ago. The surveyor and FSD proceeded to tour the kitchen together and made the following observations: -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to have an effective system in place to ensure that the required information is provided to residents or their representatives in writing when a resident is discharged to the hospital. This was found to be evident for 3 (Resident #24, #7, #61, and #43) out of 43 residents reviewed during the survey. The findings include: 1) Review of Resident #24's medical record on 3/21/24 revealed the resident had resided at the facility since April 2023. The resident was discharged to the hospital in December 2023 due to a fever. Review of the resident's paper chart revealed an Acute Transfer Letter, dated 12/12/2023. The letter included, but was not limited to, the following statement: The resident and /or the resident's representative have the right to request an impartial hearing, to be held at the facility, regarding the discharge and transfer. Details of your appeal rights will be provided by a facility representative as soon as practical…

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, interview and observations, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the residents status. This was found to be evident for 4 (Resident #24, #56, #17 and #61) out of 43 residents whose medical records were reviewed during the survey. The findings include: Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1) On 3/21/24, review of Resident #24's medical record revealed that the resident had resided at the facility for almost one year. Review of the MDS, with an Assessment Reference Date (ARD) of 2/16/24, revealed documentation that the resident had received 1 injection of insulin during the assessment reference period. Further review of the medical record failed to reveal documentation to indicate the resident received insulin…

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 interview, it was determined that the facility failed to ensure that comprehensive person centered care plans were developed. This was found to be evident for 4 (Resident #59, #17, #82 and #43) out of 43 residents whose medical records were reviewed during 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. Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. 1) Review of Resident #59's medical record on 3/20/24 revealed that the resident was admitted to the facility in the fall of 2023 with diagnoses of, but not limited to, dementia and major depressive disorder. The resident had adequate hearing and speech for communication. Review of the Minimum Data Set Assessment (MDS), with 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 observations, interviews, and records review, it was determined that the facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan, and the preferences of the residents. This was evident for 4 (Resident #82, #75, #23, and #2) of 7 residents reviewed for activities. The findings include: 1) Based on medical record review, Resident #82 was admitted to the facility in late 2023 and was cognitively intact. The resident was interviewed and observed on multiple occasions throughout the survey process, and the only activity the resident was observed in was watching TV. On 3/17/24 at 5:10 PM, Resident #82 was observed in bed watching TV. On 3/18/24 at 11:05 AM, the resident was observed in bed watching TV and was interviewed about activities. The resident reported that the facility held activities downstairs and that s/he could attend if there were enough staff to get him/her up to sit in one of the Geri chairs. There was no alternative other than watching TV in the resident's room. The resident stated, sometimes I want to get up,…

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, records review, and interviews, it was determined that the facility failed to maintain accurate documentation in the residents' medical records as evidenced by the facility's failure to ensure that staff documented behaviors to indicate the continued need for an antipsychotic medication; failed to ensure that skilled nursing notes accurately reflected a resident's status; and failed to ensure the social service director documented discharge summary/planning information.This was evident for 4 (Resident #56, #29, #10, and #42) of 43 residents reviewed during the survey. The findings include: 1) On 3/18/24, review of Resident #56's medical record revealed that the resident was admitted in September 2023. Review of the physician orders revealed that an order was in place from 1/10/24 until 2/20/24 for Risperdal to be administered two times a day for psychosis. On 2/20/24, there was an order for the Risperdal to be administered only at bedtime for 5 days and then discontinued. Risperdal is an antipsychotic medication. The above orders are called a gradual dose…

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 observation, it was determined that the facility failed to protect a resident's private space by not knocking prior to entering a resident's room. This was evident for 1 (Resident #17) out of 5 residents reviewed for dignity during the survey. The findings include: On 3/19/24 at 9:53 AM, Resident #17, a long-term resident of the facility was interviewed. During the interview, Resident #17 reported that at times, the facility staff come into the room, without knocking, when they have not been welcomed into the room. On 3/19/24 at 10:16 AM, an observation was made in the resident's room during an interview with Resident #17. The resident's door was closed. The observation revealed facility staff abruptly entered the room without knocking. The staff entered the room and addressed Resident #17 and the surveyor and said they would return later and then they left the room. On 3/19/24 at 3:05 PM, during an interview with the Director of Nursing (DON) and Administrator, they reported that the expectation is that all staff knock before entering a resident's room. 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 reviews and interviews, it was determined that the facility failed to document and address concerns raised by the resident council, as evidenced by the lack of documentation of those concerns and how they were addressed. This was evident in resident council meetings held between February 2023 and December 2023. The findings include: On 3/22/24 at 11:16 AM, a review of resident council meeting minutes for 2023, provided by the Activity Director (Staff #7), was completed. The review showed documentation of the minutes, and concerns voiced at a meeting held on 1/18/23. However, continued review failed to reveal records of the minutes and residents' concerns expressed at the February to December 2023 meetings. On 3/22/24 at 11:30 AM, during an interview with the nursing home administrator, she stated she was aware of the lack of documentation of residents' concerns or complaints voiced at the meetings from February to December 2023. The administrator also said, The resident council minutes book had changed hands in October 2023. A subsequent interview was done with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to provide information to residents regarding their right to formulate an advanced directive, failed to document that the resident or resident representative was informed of their right to formulate an advanced directive by failing to document discussions regarding advanced directives and the outcome of the discussion in the resident's medical record. This was evident for 2 (Resident #292, and #43) of 17 residents reviewed for advanced directives. The finding include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. 1) Resident #292 was a newly admitted resident of the facility. On 3/19/24, the Director of Nursing (DON) indicated that advanced directive documentation should be found in the resident's hard charts. Later that day, the Social…

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

Based on observation and interviews, it was determined that the facility failed to provide information on the facility's grievance procedures and how to file complaints or grievances available to residents. This was evident during a resident council meeting conducted during the annual survey. The findings include: On 3/22/24 at 9:33 AM, the surveyor attended a resident council meeting with five residents, including the president and vice presidents of the resident council. During the meeting, the residents stated that they did not know if the facility had a procedure, including a specific form, for filing grievances generated from the Resident Council meetings or by individual residents. The residents also stated they did not know who the facility's grievance officer was to assist them. Residents #49 and #30 were interviewed on 3/22/24 at 10:26 AM. During the interview, they stated they were unaware of the facility's formal grievance filing process. They also expressed concern that, residents who could not leave their rooms, could file a grievance. On 3/22/24 at 10:59 AM, the Social…

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 failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was for 3 (Resident #7, #61 and #43) of 43 residents reviewed during the survey. The findings include: 1) Review of Resident #7's medical record on 3/26/24 at 9:19 AM revealed documentation that Resident #7 had been transferred to an acute care facility on 5/30/24 and 6/24/24 and failed to reveal evidence that the resident was oriented and prepared for the transfers in a manner s/he could understand and there was no documentation of the resident's understanding of the transfer. 1a) On 5/30/24 at 6:47 PM, in a SBAR (acronym for situation, background, assessment, recommendation), the nurse documented that Resident #7 complained of stabbing chest pain, the resident had a low pulse oxygen level, and bilateral rhonchi (low-pitched wheezes or coarse crackles in the lungs). The nurse further documented that the primary care provider (PCP) was notified and responded with an order to send the resident to…

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

Based on medical record review and staff interview, it was determined the facility failed to ensure residents were made aware of a facility's bed-hold and reserve bed payment policy when transferred to a hospital. This was evident for 3 (Resident #7,#61 and #43) of 43 residents reviewed during the annual survey. The findings include: 1) On 3/26/24 at 9:19 AM, a review of Resident #7's electronic medical record (EMR) revealed Resident #7 was transferred to an acute care facility on 6/24/23 with no documentation found to indicate the resident and/or the resident's representative was given written notice of the facility's bed hold policy at the time of the resident's transfer, or in cases of emergency transfer, within 24 hours. On 6/24/23 at 9:45 PM, in a SBAR note, the nurse documented that Resident #7 complained of swelling and right wrist pain following an unwitnessed fall in the facility, the physician was made aware, and ordered the resident be sent to the ER for further evaluation. On 6/24/23 at 9:45 PM, in a Transfer Form, the nurse documented Resident #7 was transferred to 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 staff interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in a resident's condition. This was evident for 1 (#88) of 3 residents reviewed for closed records. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The nursing home should complete a significant change in status MDS assessment within 14 days when there's a major decline or improvement in a resident's status. A medical record review completed on 3/20/24 at 1:57 PM for Resident #88 showed that they were admitted to the facility in February 2023, with diagnoses that included Dementia and Diabetes. Further review revealed that Resident #88 was seen by the attending provider on 12/4/23 for increased…

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

Based on medical record review and interview, it was determined that the facility failed to accommodate a resident's schedule to ensure the resident was able to participate in the interdisciplinary care plan meeting. This was found to be evident for 1 (Resident #76) out of 43 residents reviewed during the survey. The findings include: 1) Review of Resident #76's medical record revealed the resident had resided at the facility for more than a year. During an interview on 3/19/24 at 2:44 PM, the resident's representative expressed a concern that, due to a scheduling conflict, the resident was unable to actually participate in the care plan meeting held earlier that day. The meeting was scheduled for 11:45 AM and transportation for an outside appointment was scheduled for 12 noon. The representative reported that transportation showed up and was going to leave without the resident. The resident did sign in to the meeting, but did not participate because s/he had to leave. Each resident has the right to participate in choosing treatment options and must be given the opportunity 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, interviews, and records review, it was determined that the facility failed to provide necessary services to maintain good personal hygiene to residents who are dependent on staff and/or who are requiring assistance from staff with activities of daily living (ADL). This was evident for 2 (Resident #15 and #75) of 2 residents reviewed for ADL's. The findings include: 1) Resident #15 had been residing in the facility since 2021. On 3/18/24 at 9:48 AM, the resident reported that s/he had a horrible time last night since s/he had to be given a suppository for not moving his/her bowels for a long time. The resident indicated that, after being cleaned, s/he was still going and stated, I laid here for like 3 hours with dirty stuff under me, poop and pee. On 3/21/24 at 3:18 PM, a review of Resident #15's medication administration record (MAR) confirmed the administration of an as needed suppository on 3/17/24 at 2:48 PM for bowel health. Further review of the MAR revealed that the resident was routinely taking Senna Plus oral tablet, twice a day and Colace oral capsule…

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, interviews and observations, it was determined that the facility failed to ensure the administration of regularly scheduled medications; failed to ensure that recommendations made by the registered dietitian were communicated to the physician; and failed to ensure that staff followed a physician order to notify the physician when a lab value was outside of an ordered parameter. This was found to be evident for 3 (Resident #56, # 29, and #17) out of 43 residents reviewed during the survey. The findings include: 1) On 3/18/24, review of Resident #56's medical record revealed the resident had been receiving Hospice services since September 2023. Hospice is a program that gives special care to people who are near the end of life. The resident had current orders, in effect since 2/29/24, for Venlafaxine to be given three times a day for depression; for Risperdal to be administered two times a day for psychosis and Lorazepam (Ativan) to be given every 4 hours for terminal agitation. Lorazepam, which is frequently prescribed for residents on hospice, is 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and observation, it was determined that the facility failed to identify and establish treatment orders for a newly acquired pressure ulcer and failed to ensure that treatment orders were updated as indicated by the wound care provider. This was found to be evident for one (Resident #24) out of two residents reviewed for pressure ulcers. The findings include: Review of Resident #24's medical record revealed the resident was admitted in 2023. The resident had functional limitations in range of motion for upper and lower extremities (arms and legs) on both sides and was dependent on staff for assistance with toileting, bathing, bed mobility and transfers from bed to a chair. A care plan addressing risk for alteration in skin integrity was established shortly after admission. On 7/31/23, a pressure ulcer was identified on the resident's left buttocks and treatment orders were initiated. The resident had several hospitalizations in the fall of 2023. Pressure ulcers are…

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 interview, it was determined that the facility failed to ensure that occupational therapy recommendations for a restorative nursing plan were discussed with the interdisciplanary team or incorporated into the resident's care plan. This was found to be evident for one (Resident #24) out of three residents reviewed for positioning and mobility. The findings include: Review of Resident #24's medical record revealed that the resident was admitted in 2023. The resident had functional limitations in range of motion for upper and lower extremities (arms and legs) on both sides and was dependent on staff for assistance with toileting, bathing, bed mobility and transfers from bed to chair. Review of the 2/16/24 Minimum Data Set assessment revealed that the resident had not recently received therapy and currently was not receiving restorative nursing program services. On 3/22/24, review of the Occupational Therapy Discharge summary, dated [DATE], revealed the discharge recommendations…

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

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that residents were free from accident hazards when smoking, by failing to follow a resident's care plan to implement adaptive equipment when the resident smoked. This was evident for 1 (Resident #7) of 8 residents reviewed for accidents. The findings include: On 3/26/24 at 8:59 AM, a review of Resident #7's medical record revealed a Smoking Assessment, with an effective date of 1/18/24 at 9:27 AM, that documented Resident #7 smoked cigarettes and assessed their ability to smoke safely. The assessment documented that Resident #7 had a visual deficit, a dexterity problem, the resident could not light his/her own cigarette and s/he could not dispose of a cigarette appropriately. The safety assessment identified that, when smoking, Resident #7 needed supervision, and needed to wear a smoking apron (protects clothing and skin from burns and hot ashes). Review of Resident #7's care plans revealed a care plan, [Resident #7] utilizes nicotine products r/t (related to) lifestyle;…

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

Based on medical record review and staff interview, it was determined the facility failed to provide the necessary care and services for a resident with suprapubic catheter by failing to ensure a follow-up urology consult was scheduled as recommended after a hospitalization. This was evident for 1 (Resident #80) of 3 residents reviewed for urinary catheter. The finding includes: An indwelling urinary catheter is a tube inserted into the bladder and left in the bladder to drain urine. Often known as a Foley catheter, the catheter is held in the bladder by a water-filled balloon, which prevents it from falling out and allows urine to flow through it and into a drainage bag. These catheters are most commonly indwelling urethral catheters (IUC) inserted into the bladder through the urethra (the canal that carries the urine out of the bladder). A suprapubic (SP) is an indwelling catheter that was inserted into the bladder through a small surgical incision in the abdomen. 1) On 3/26/24 at 11:29 AM, a review of the medical record revealed that when Resident #80 was initially admitted 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 records review and interviews, it was determined that the facility to ensure pain management was provided to a resident requiring this service. This was evident for 1 (Resident #15) of 7 residents reviewed for pain management. The findings include: Resident #15 had been residing in the facility since 2021. On 3/18/24 at 10:35 AM, the resident was interviewed and indicated that s/he was in constant pain at a level of 9 to 10 where 10 being the highest. The resident also reported that pain medications help, but must be taken routinely. The resident stated, I have to ask for them because sometimes they are late. On 3/21/24 at 3:05 PM, Resident #15's medical records were reviewed and revealed orders for pain management with different classes of medication to treat the resident's pain. Later at 3:18 PM, the resident's medication administration record (MAR) was reviewed for the month of March and revealed the order for Diclofenac Sodium Gel to be applied to the resident's knees, ankles, and both feet, every 6 hours, was not marked as administered on the 14th, 15th, and 20th for…

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

Based on medical record review and interviews, it was determined that the facility failed to ensure transportation for regularly scheduled dialysis treatment, failed to follow up with the dialysis center to obtain a report after a dialysis treatment, and failed to notify the primary care provider when a dialysis session was missed. This was found to be evident for one (Resident #29) out of one resident reviewed for dialysis. The findings include: Review of Resident #29's medical record revealed an admission in February 2024 after a hospitalization for an infection. The resident's diagnosis included, but was not limited to, end stage renal disease with dependence on renal dialysis. The resident was scheduled to attend dialysis on Tuesday/Thursday and Saturdays at 11:00 AM at a dialysis center not located within the facility. Dialysis is a treatment that filters and purifies the blood using a machine in people whose kidneys can no longer perform these functions naturally. End-Stage Renal Disease (ESRD) is the stage of kidney impairment that appears irreversible and permanent, and…

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

Based on observations, interviews, and records review, it was determined that the facility failed to assess residents for safety or obtain informed consent prior to the installation of bed rails, and failed to obtain orders or establish a care plan to address the use of side rails. This was evident for 3 (Resident #56, #82, and #15) of 8 residents reviewed for accidents. The findings include: 1) Review of Resident #56's medical record revealed that the resident was originally admitted to the facility in September 2023. The resident had severe cognitive impairment and was dependent on staff for activities of daily living such as eating, bathing and dressing. The resident did not have any functional limitations to range of motion in either the arms or the legs. On 3/17/24 at 1:58 PM, Resident #56 was observed in bed with padded quarter side rails in the up position on both sides of the bed. On 3/19/24 at 09:05 AM, the resident was observed in bed with padded quarter side rails in the up position on both sides of the bed. Review of the medical record on 3/21/24, revealed a Bed Safety…

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

Based on medical record review and interview, it was determined that the facility failed to ensure residents were free from unnecessary medication. This was found to be evident for two (Resident #24 and #191) out of seven resident's whose medication regimens were reviewed during the survey. The findings include: 1) On 3/22/24, a review of Resident #24's medical record revealed a current order, with a start date of 12/20/23, for Midodrine to be given three times a day for hypotension, and to hold for a SBP [systolic blood pressure] greater than 110. Hypotension is low blood pressure. The systolic blood pressure is the top number of a blood pressure reading. Low blood pressure can lead to dizziness and fainting. Review of the Medication Administration Record for March 2024 revealed multiple occasions when the resident's SBP was greater than 110 and the medication was administered. These dates include: 3/21 afternoon dose 3/20 morning dose 3/18 afternoon dose 3/14 evening dose 3/5 morning dose On 3/22/24 at 12:36 PM, the unit nurse manager (Staff #9) confirmed that the current…

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 interview, it was determined that the facility failed to ensure that a prn (as needed) order for an antipsychotic medication was limited to 14 days. This was found to be evident for one (Resident #24) out of five residents selected for unnecessary medication review. The findings include: Review of Resident #24's medical record revealed the resident was admitted in 2023. The resident had several hospitalizations in the fall of 2023. On 3/20/24, review of the medical record revealed that the Consultant Pharmacist Recommendation to Physician on 11/2/23 included the following: Resident has the following order: Promethazine 12.5 mg Give 25 mg by mouth every 8 hours as needed for nausea or vomiting. Promethazine can technically be classified as a phenothiazine psychotropic medication -- please consider adding a duration of therapy/stop date for the above order. The form indicated that the prescriber agreed with the recommendation on 11/6/23. Review of the physician orders revealed 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 observations and staff interviews, it was determined that the facility failed to ensure that 1) expired medications were disposed of promptly and 2) medications were stored correctly per the manufacturer's specifications. This was evident for 3 of 4 medication carts observed and 1 of 2 medication rooms observed. The findings include: 1a) On 3/25/24 at 12:54 PM, the 3rd-floor nurses' medication cart was observed in the presence of Staff #33, a registered nurse (RN). The observation revealed five vials of ipratropium bromide and albuterol sulfate inhalation solution and a second pack with two vials, all available for use, with the expiration dates of 12/2023, for Resident #78. Staff #33 confirmed they were expired and should have been discarded. 1b) An observation of the 3rd-floor medication storage room refrigerator in the presence of Staff #33 on 3/25/24 at 1:30 PM revealed a COVID-19 vaccine, with an expiration date of 12/22/23, for Resident #40 and another COVID-19 vaccine with an expiration date of 12/25/23 for Resident #14. Staff #33 stated they were expired and should…

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, records review, and interviews, it was determined that the facility failed to ensure that food and drink was provided to the resident. This was evident for 1 (Resident #292) of 3 residents reviewed for food. The findings include: Resident #292 was a newly admitted resident of the facility that arrived on a weekend. On 3/17/24 at 3:07 PM, the resident was observed in bed and stated, I want to go back to the hospital because they're not treating me well, like I have to remind them to give me my meals. The resident indicated that this was every mealtime. Later at 6:06 PM, the resident reported that s/he was upset because s/he had not received his/her dinner tray. Resident #292 indicated that his/her roommate received a dinner tray like usual but not him/her. The resident's roommate was observed with a dinner tray that was about 50% consumed at that time. Two staff were observed about 4 rooms down the hall passing dinner trays. When the staff saw the surveyor walk in Resident #292's room, 1 staff peeked in the resident's room and told the other staff, His/Her tray…

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 residents requiring pureed diets received adequately pureed foods. This was found to be evident for two out of two residents (Resident #34 and #19) observed to have incorrect diet consistency served during a random observation. The findings include: On 3/21/24 at 12:39 PM, while touring the kitchen with the Food Service Director (FSD Staff #8) a test tray was pulled at random from the cart as it was preparing to leave the kitchen, the meal ticket was given back to staff to make another tray. The tray had multiple thickening packets, which were given back to kitchen staff prior to removing the tray from the kitchen. Surveyor and FSD observed three items on the plate: one scoop of white/cream colored item, one rounded scoop of chopped up ravioli, and a finely chopped up, but not smooth pudding like puree, of a green bean item. The FSD confirmed the ravioli and green bean items would be considered ground, not pureed. The FSD and surveyor reviewed the diet list for the residents…

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

Based on observation and interview, it was determined that the facility failed to ensure that refuse was properly disposed. This was found to be evident on 2 out of 2 observations of the dumpster area. The findings include: On 3/21/24 at 3:00 PM, observation of the dumpster area revealed various debris noted on the ground including multiple cans and cups from a convience store. An old mattress was observed on the ground behind one of the dumpsters. On 3/21/24 at 3:37 PM, when asked who was responsible for the dumpster area, the Food Service Director reported it was not dietary staff, but environmental services or maintenance. On 3/29/24 at 9:09 AM, observation of the dumpster area again revealed various debris, although somewhat different than debris observed on 3/21, the mattress remained behind the one dumpster. At 9:15 AM, the area was observed with the Nursing Home Administrator who confirmed it was a facility mattress. Surveyor reviewed the concern that it had originally been observed on 3/21/24.

Based on review of medical records and other pertinent information and interview, it was determined that the facility failed to develop and implement appropriate plans of action to correct identified deficiencies. This deficient practice has the potential to affect all residents. The findings include: On 3/29/24, review of the last two recertification surveys revealed several deficiencies that were identified again during this survey which had similarly identified findings. These included deficiencies in regard to MDS inaccuracies (F 641), comprehensive care plans (F 656) and restorative nursing (F 688). Additionally, a complaint survey conducted in January 2024 also identified deficiencies related to MDS inaccuracies and comprehensive care plans. Review of the plans of corrections for the MDS and care plan related deficiencies revealed they primarily addressed the specific examples that evidenced the deficient practice rather than the processes involved in the deficiency. On 3/29/24 at 11:05 AM, the Nursing Home Administrator (NHA) reported that nurse (Staff #10) had been the QA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, it was determined that the facility failed to 1) ensure that staff kept the door between the clean and dirty areas of the laundry closed to prevent cross contamination; 2) to have measures in place to monitor for and prevent the growth of legionella and other opportunistic water-borne pathogens in its water systems; 3) to maintain a residents catheter bag in proper a sanitary condition; and 4) to ensure that PPD skin test are read within the 48-72-hour timeframe. This was found to be evident for 1 (Resident # 80) out of 3 residents reviewed for urinary catheter use and 1 (Resident #191) of 6 residents reviewed for tuberculosis skin testing. The findings include: 1) On 3/17/24 at 3:34 PM, the door to the laundry was open and accessible from a secured hall. The door between the clean area, where the dryers and clean folded laundry are kept, and the dirty area where the washers are located, was noted to be open. A washer was running at this time and no staff 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 interview, observation, and pertinent document review, it was determined that the facility failed to have a monitoring process in place to ensure that the resident call system remained functioning. This was evident for 4 out of 12 rooms, during a random observation. The findings include: On 3/18/24 at 9:40 AM, during an interview with Resident # 7, a long-term resident of the facility, s/he reported that his/her call light had not worked for some time. Resident # 7 reported that, when s/he pressed the call system device, there was an audible sound but the light outside her room above the door frame did not light up. S/he reported that s/he had told staff that it was not working. On 3/18/24 at 9:43 AM, an observation was made of Resident #7 when s/he pressed his/her call system device at the bed side. Observation outside of the Resident #7's room failed to reveal an illuminated light outside of the resident's room. Further observation failed to reveal a bell or substitute call system in Resident # 7'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 medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents (Resident #1, #7 and #21). This was evident for 3 of 29 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. 1. Review of Resident #1's medical record on 1/3/24 revealed the Resident was admitted to the facility…

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

Based on medical record review and interview, it was determined the facility staff failed to provide urinary catheter care to Resident #28 as ordered. This is evident for 1 of 1 resident reviewed during the complaint survey process. The findings include: Investigation of complaint MD00200031 revealed the following: On 1/11/24 at 11:30 AM a review of Resident #28's clinical record revealed that the resident's primary physician wrote an order on 6/21/23, Patient has Foley catheter 16Fr; Balloon size 10 ml, to continuous drain. Diagnosis for use Neurogenic Bladder Provide privacy bag and to change indwelling Catheter and drainage bag every 30 days and when needed. An indwelling urinary catheter (tube) in the bladder is a pliable catheter that drains urine from the bladder into a bag outside the body. A common reason to have an indwelling catheter is urinary retention (not being able to urinate). A neurogenic bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem). Further review of the electronic medical record for Resident #28…

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 staff failed to include a resident's Power of Attorney (POA) in the care of a resident (Resident #21) This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: Review of Resident #22's medical record on 1/3/24 for a concern from Resident #22's POA in February 2023, that he/she has been requesting Physician #1 to contact him/her since the Resident's admission in November 2022, revealed the Resident was admitted to the facility on [DATE] and has a POA listed. Further review of Resident #22's medical record revealed on 1/9/23 the facility staff held a care plan meeting with the Resident's POA and documented, Nursing Unit Manger to have doctor reach out to the POA to discuss lab results. Further review of Resident #22's medical record revealed the first documentation of a physician speaking to the Resident's POA is on 9/23/23 by the Medical Director who is currently the Resident's physician. During…

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

Based on observation and interview, the facility failed to provide maintenance and housekeeping services to maintain a safe, clean, comfortable and homelike environment for residents (Residents #7, #21 and #27). This was evident for 3 of 29 residents reviewed during a complaint survey. The findings include: 1. Observation of Resident #7's room on 1/4/24 at 1:40 PM revealed the corner popcorn ceiling spackle hanging down exposing a gray material underneath. During interview of Resident #7 at that time, he/she stated the ceiling has been like that because every time it rains it leaks from the ceiling. Observation of the Resident's bathroom revealed 2 ceiling tiles that were stained, cracked and buckling. The Surveyor brought the Maintenance Director to Resident #7's room on 1/4/24 at 1:55 PM and the Maintenance Director confirmed the ceiling and bathroom tiles needed repair. 2. Observation of Resident #21's room on 1/9/24 at 11:50 AM revealed one bath basin on the bathroom floor and 3 bath basins stacked sitting on the back of the toilet unmarked and uncovered. At that time the front…

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 facility documentation review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) for residents (Resident #8, #11 and #13). This was evident for 3 of 7 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1. Review of the investigation of a facility reported incident for alleged abuse of Resident #8 revealed on 10/14/21 at 3:30 AM Resident #8 reported to RN #2 alleged abuse by GNA #4. Further review of the facility investigation revealed the facility staff called the police on 10/14/21 at 12:00 PM but failed to notify OHCQ until 10/15/21 at 9:15 AM. Interview with the Administrator and Director of Nursing on 1/5/24 at 10:25 AM confirmed the facility staff failed to notify OHCQ of an incident of alleged abuse of Resident #8 in a timely manner. 2. Review of the investigation of a facility reported incident for alleged abuse of Resident #11 revealed on 2/2/22 at 1:08 PM the Resident reported in a care…

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 interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded (Resident #18). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #18's medical record on 1/3/24 revealed the Resident was admitted to the facility on [DATE] and has a diagnosis to include history of falling. Further review of Resident #18's nurses' notes revealed it was documented the Resident slipped to the ground or fell on 9/28/22, 10/13/22, 10/14/22 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 clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had baseline care plans created and initiated for a resident. This was evident for 1 (#12) out of 29 residents in the survey sample. The findings are: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. An investigation into intake #MD00180291 was initiated by the survey team on 1/9/24. The clinical record review revealed an absence of baseline care plans. The resident had cervicalgia, dysphagia, cognitive decline, vascular disease and had other conditions which…

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 the review of a complaint, medical record review and interview with staff, it was determined that the facility failed to implement an effective discharge planning process for residents (Resident #3 and #9). This was evident for 2 of 29 residents reviewed during a complaint survey. The findings include: 1. Review of a complaint from Resident #3's Representative that he/she was not advised of the Resident's care needs or the Resident's discharge on [DATE] to the Representative's home. Review of Resident #3's medical record on 1/4/24 revealed the Resident was admitted to the facility on [DATE] from the hospital. Further review of the Resident's medical record revealed no Social Worker's notes or care plan meeting discussing Resident #3's discharge plan or communication with the Resident's representative regarding the Resident's discharge on [DATE]. Interview with the Director of Nursing and Administrator on 1/4/24 at 10:35 AM confirmed the facility staff failed to have an effective discharge plan in place…

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, the facility staff failed to perform activities of daily living for a dependent resident (Resident #1). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: Review of Resident #1's medical record on 1/3/24 for a complaint about not being changed for 5 hours on 3/4/23 revealed the Resident was admitted to the facility on [DATE] and was discharged from the facility on 4/27/23. Interview with Resident #1 on 1/3/24 at 10:25 AM, the Resident stated on 3/4/23 he/she was not changed for about 5 hours and had to lay in his/her own urine and feces. Further review of Resident #1's medical record revealed on 2/21/23 the facility staff completed Resident's annual MDS (Minimum Data Set) Assessment and coded the Resident in Section G0110 Activities of Daily Living (ADL) Assistance as an extensive assistance and 2+ person physical assist for Toilet Use. Review of the facility investigation for this incident revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #10 and #12). This is evident for 2 of 29 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their 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), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer…

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 physician progress notes were not in a resident's medical record the day the resident was seen (Resident #22). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: Review of Resident #22's medical record on 1/3/24 revealed the Resident was admitted to the facility on [DATE] and currently resides in the facility. Further review of Resident's medical record revealed the first physician note is on 4/27/23 by the Medical Director. Prior to 4/27/23 the Resident was under the care of Physician #1. Interview with the Director of Nursing on 1/9/24 at 2:12 PM confirmed their are no physician notes for Resident #22 from admission on [DATE] until 4/27/23. The Director of Nursing also confirmed at that time Physician #1 no longer works at the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to provide dental care for a resident (Resident #14). This was evident for 1 of 29 residents reviewed during a complaint survey. The findings include: During interview with Resident #14's representative on 1/8/24 at 1:33 PM, he/she stated the Resident was admitted to the facility on [DATE] with his/her dentures and when he/she visited the Resident on 5/29/21, the Resident's dentures were missing. The Resident's representative stated the facility staff stated they were going to replace the dentures but it never happened and the Resident returned home on 4/26/23 without dentures. Review of Resident #14's medical record on 1/8/24 revealed the Resident was admitted to the facility on [DATE] and the facility staff documented on the Resident's Personal Effects Inventory the Resident had both upper and lower dentures. Review of Resident #14's Speech Therapy Treatment Encounter Notes revealed on 5/20/21 the Speech Therapist (ST)…

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, medical record review, and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #2 and #7) This was evident for 2 of 29 residents reviewed during a complaint 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. All entries to the record should be legible and accurate. 1. Review of Resident #2's medical record on 1/4/24 revealed the Resident was admitted to the facility on [DATE] from the hospital following joint replacement surgery. On 9/27/21 the facility staff completed a Minimum Data Set discharge assessment and coded the Resident as an unplanned discharge to the hospital. Further review of Resident #2's medical record revealed no nurse's note or assessment to…

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

Based on medical record review and interview it was determined that the facility to ensure comprehensive care plans were developed for residents as evidenced by failure to address: 1) respiratory issues including sleep apnea and the use of oxygen; 2) the use of psychotropic medications; 3) individual's activity preferences 4.) psychotropic and hypnotic medications 5.) hospitalizations and infections; and 6.) failed to develop a care plan related to a resident's respiratory needs. This was found to be evident for 6 out of 27 residents (#90, #81, #30, #211, #88, #57) reviewed during the investigation stage of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1. On 4/23/19 the Resident #90 reported having had a sleep study about the first of the month. On 4/26/19 review of the medical record revealed a sleep study report dated 2/4/19 which…

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, interview of residents, family and of facility staff, it was determined that the facility failed to: 1) have an interdisciplinary team (IDT) meeting consisting of the resident and or resident representative upon admission to the facility and with subsequent admission (Resident #96). During this meeting a care plan is developed or revised; 2) failed to update the resident care plan for a resident (Resident # 81) observed sitting in the bedroom with a large wet area underneath the wheelchair and 3) failed to update a care plan for a resident (Resident #47) receiving treatment for a pressure ulcer; 4.) failed to conduct quarterly care plan meetings with the resident or the responsible party to address the resident's current needs (Resident #110) This was evident for 4 of 27 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. An interview was conducted on 4/22/19 at…

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 staffing documentation, complaint MD00133305 and interviews it was determined that the facility failed to ensure sufficient nursing staff to provide services to maintain the highest practical physical, mental and psychosocial well-being of each resident. This deficient practice has the potential to affect all the resident's in the facility. The findings include: Review of MD00133305 revealed an allegation that the facility is short staffed, that residents have to wait 30 - 45 minutes to have their call light answered because the facilty only has 2 GNAs [geriatric nursing assistants] for 50 residents. On 4/22/19 at 10:51 AM Resident #18 reported the call bells go off and remain unanswered and that [s/he] closes the door so [s/he] doesn't have to hear it. On 4/23/19 at 10:51 AM Resident #110 reported that staffing is a major issue at this facility, s/he further reported that [s/he] puts on the light and sometimes they come right away but most times [s/he] has to wait, because they are short staff. The resident reported that staff does not take the time to pull…

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 surveyor observation and interview with staff it was determined that the facility failed to keep speech language pathology instructions for the resident in a private setting and failed to promote dignity for the resident by giving instructions and feeding the resident at the nursing station which is also located in front of the elevator. This was true for 1 out 7 residents (Resident #52) reviewed for dignity during the investigation stage of the survey. The findings include: During the initial tour of the facility on 4/24/19, Resident #52 was noted to be sitting on the side of the nursing station visible to all residents, staff and visitors. Further observation revealed the resident frequently yelling I wanna eat. Further tour of the facility revealed a dining area. On 4/25/19 review of the lunch service revealed staff passing out trays leaving Resident #52 to be served last. During an interview with Staff #12 the surveyor asked why the resident was being served last and she replied because Resident #52 needs to be fed. After trays had been passed the surveyor observed…

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 family and facility staff, it was determined that the facility failed to 1. have a system in place to document a change in condition timely and further notify a resident's representative timely of a change in condition for Resident #212 evident during the review of a fall; 2. notify the physician that scheduled medication was unavailable to administer to a resident (Resident #27). This was found to be evident for 2 of 27 residents reviewed during the facility's annual survey. The findings include: 1. During tour of the facility on 4/24/19 at 11:06 AM, Surveyor was notified by Resident #212's family member that Resident #212 had a fall either the previous night or the morning of 4/24/19 and the representative was not notified until he/she had arrived at the facility on 4/24/19. Review of Resident #212's medical record on 4/24/19 at 11:09 AM failed to reveal any documentation of a fall within the past 24 hours. On 4/30/19 at 9:16 AM surveyor requested all investigations related to falls that occurred with Resident #212 in the past 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews it was determined that the facility failed to maintain the physical environment of the facility in good repair as evidenced by multiple cracked and damaged floor tiles in hallways and resident rooms; damage to walls and doors; loose fitting plumbing fixtures; and resident sinks with a tanish colored build-up on the ledges. The findings include: The following observations were made during the survey: 04/26/19 10:27 AM 3rd floor shower room: approximately 4 inch area of door way into shower noted to be in disrepair; caulking in the shower noted to be cracked. On 4/26/19 at 11:26 AM room [ROOM NUMBER]: damage to doorframe approximately 4 inches x 3 inch; floor noted with stains; crack running almost the entire width of the room noted in the paint on the ceiling near where the ceiling meets the wall above the window. On 4/26/19 at 11:53 AM in the 2nd floor therapy room: damage to wall approximately a 10 inch x 4 inch area noted at the level where a hand sanitizer dispenser could…

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, medical records review and interview it was determined that the facility failed to have a system in place to keep track of a resident's purchases. This was true for 1 out of 3 residents (Resident #22) reviewed for personal property. The findings include Review of complaint MD00137346 on 5/1/19 revealed Resident #22 reported that the facility had put the resident's belonging in storage, however when the resident asks for certain items the facility had not been able to provide the resident with the requested items. During an interview with the Administrator or 5/1/19 he verbalized that he was very familiar with the resident. He also stated that the resident in the past was constantly ordering things from the television. He further reported that when the boxes arrived, he would take them to the resident's room where they would be opened, and the resident would decide which items to keep in the room and which items would be put in storage. On 5/1/19 the administrator provided the survey team with 4 pages of itemized purchases with the price of each item 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.

Based on medical record review, interview with family, staff and the ombudsman determined that the facility failed to have a system in place to ensure that the resident and/or resident's representative and the ombudsman were notified in writing of the resident's transfer to the hospital and the rationale for the transfer. This was found to be evident for 3 of 5 residents (Resident #54, #96, #211) reviewed for hospitalization during the investigative portion of the survey and related complaints. Findings include: 1. On 4/30/19 review of Resident #54's medical record revealed the resident had been discharged to the hospital in March 2019. Further review of the medical record failed to reveal documentation that the resident, or a responsible party, had been provided with the required transfer information in writing. On 5/1/19 at 1:24 AM surveyor reviewed the concern with the Director of Nursing regarding the failure to provide the required information when residents are discharged to the hospital. 2. A medical record review for Resident #96 was completed on 04/26/19 at 9:55 AM Resident…

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 recent facility discharge practices and interview with facility staff, it was determined that the facility failed to provide residents and or their representative (RP) with the proper paper documentation of the facilities bed-hold policy. This was evident for 3 of 5 residents (Resident #54, #96, #211) reviewed for hospitalization during the investigative portion of the survey and related complaints. The findings include: 1. On 4/30/19 review of Resident #54's medical record revealed the resident had been discharged to the hospital in March 2019. Further review of the medical record failed to reveal documentation that the resident, or a responsible party, had been provided with the required bed-hold policy in writing at the time of transfer. On 5/1/19 at 1:24 AM surveyor reviewed the concern with the Director of Nursing (DON) regarding the failure to provide the required information when residents are discharged to the hospital. 2. A medical record review for Resident #96 was completed on 04/26/19 at 9:55 AM Resident #96 was noted to be hospitalized twice since…

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 medical records and interview with staff it was determined that the facility failed to have an effective system in place to ensure Minimum Data Set (MDS) assessments were completed at least once every three months. This was found to be evident for the 2 out of 2 residents (Resident #1 and #3) reviewed as part of the Resident Assessment task during the annual survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD). 1. On 4/30/19 review of Resident #1's medical record revealed a quarterly MDS, with an assessment date of 12/18/19 was submitted to CMS on 1/6/19. Further review of the medical record revealed an annual MDS, with an assessment reference date of 3/20/19, which was currently In Progress and as such was neither completed nor submitted to CMS. 2. On 4/30/19 review of Resident #3's medical record revealed an MDS with an assessment reference date of 12/19/18. 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.

Based on review of medical records and interview with staff it was determined that the facility failed to have an effective system in place to ensure Minimum Data Set assessments were transmitted within the required timeframes. This was found to be evident for the 3 out of 3 residents (Resident #1, #3 and #88) reviewed as part of the Resident Assessment task during the annual survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD). 1. On 4/30/19 review of Resident #1's medical record revealed a quarterly MDS, with an assessment date of 12/18/19 was submitted to CMS on 1/6/19. Further review of the medical record revealed an annual MDS, with an assessment reference date of 3/20/19, which was currently In Progress and as such was neither completed nor submitted to CMS. 2. On 4/30/19 review of Resident #3's medical record revealed an MDS with an assessment reference date of 12/19/18. 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.

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to accurately code the resident vision in section B. This was found to be evident for 1 out of 7 residents (Resident # 28) reviewed during the investigative stage of the survey. The findings include: The Minimum data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Its designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. MDS assessments need to be accurate to ensure each resident receives the care they need. On 5/1/19 Resident #28's medical records were reviewed and revealed that the resident was admitted to the facility for rehabilitation and long-term care with diagnosis that included legal blindness as defined in the United States. The resident's MDS with an Assessment Reference Dates (ARD) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff it was determined that the facility failed to have a system in place to provide a summary of the interim plan of care to the resident or responsible party. This was found to be evident for 2 out of 3 residents (Resident #312 and #57) reviewed for care planning in the investigative stage of the 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. 1. On 4/26/19 Resident # 312's medical records were reviewed and revealed that the resident was admitted in March 2019 for respite care and with diagnosis and concerns including seizure disorder stroke and tooth pain Further review of the medical record failed to reveal documentation to indicate a baseline care plan and the summary of the initial care plan had been provided to the resident or the responsible family member. On 4/26/19 the surveyor requested a copy of 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 with facility staff, it was determined that the facility failed to have an updated physician discharge summary and a completed discharge summary on a resident to include a recapitulation of the resident's stay. This was evident in 1 of 3 residents (Resident #311) reviewed for discharge. The findings include: On 5/1/19 Resident #311's closed record was reviewed, and revealed that the resident was discharged from the facility in March 2019. Further review of the closed records revealed a physician discharge summary. This physician discharge summary was missing the date of admission for the resident and a missing signature of who the discharge instructions were given to at the time of discharge. Review of the discharge summary; recapitulation of stay was incomplete. Information for follow-up appointments was missing dates and time. Review of the social service final summary was missing all information, such as discharge date , discharge location discharge goals and any additional information the resident may need on discharge. There was no…

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 interview with resident and facility staff it was determined that the facility failed to consistently ensure the resident's personal hygiene needs were adequately met when the resident received limited showers. This was evident for 1 of 8 residents (Resident #18) reviewed for activities of daily living in the investigation stage of the survey. The findings include: 1. During an interview with Resident #18 on 4/24/19 the resident revealed that he/she had not had a shower in weeks. The resident further reported that the shower days should be twice a week. On 4/25/19 medical records were reviewed and revealed that the resident was admitted to the facility for rehabilitation and for long term care with diagnoses that included anxiety disorder, diabetes and major depression. During an interview with Staff #9 on 4/25/19 the surveyor asked her what days the resident shower days were, Staff #9 reported that the resident shower days were changed to accommodate the resident. She further reported that the shower days were Wednesday and Saturday. Review of…

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

Based on observation, interview with staff and family members and review of medical record, it was determined that the facility staff failed to provide activates of daily living specific to grooming on a daily basis to the resident. This was evident of 1 out of 27 residents (Resident #91) reviewed in the investigational process of the survey. Findings include: Observation of Resident #91 on 4/22/19 at 10:06 AM revealed a basin of water and a dry wash cloth on his/her bedside tray. The resident was again observed at 11:02 AM with the same basin of water and a dry wash cloth in the same place as earlier observed. The resident was dressed in a hospital gown and had stringy, matted hair on his/her head. Observation of Resident #91 on 4/23/19 at 10:41 AM and at 2:44 PM revealed the resident to be awake, dressed in a green hospital gown and her/his hair was matted and oily looking. Interview with Geriatric Nursing Assistant (GNA) #23 on 4/23/19 at 11:07 AM revealed the resident was resistive to care. Interview with the resident's brother and mother on 4/26/19 at 10:27 AM revealed 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, observation and interview with facility staff it was determined that the facility failed to provide activities for an individual based on their assessment. This was evident in the review 2 of 4 residents (Resident #30 and #211) reviewed for activities. The findings include: 1a. Resident #30 was observed on 4/23/19 at 10:42 AM and was noted asleep in the bed. On 4/29/19 at 12:00 PM, Resident #30 was noted in the room with the television on. Various tours of the second floor between those times failed to reveal any involvement of Resident #30 with any activities or staff other than the television occasionally on. Review of the medical record for Resident #30 revealed diagnoses including a history of a traumatic brain injury (TBI), cognitive communication deficit and paraplegia. Review of the resident's care plan on 4/25/19 at 12:00 PM revealed initiation of an activities care plan on 3/11/19 that the resident is dependent on staff for activities, cognitive stimulation and social interaction. In addition, the intervention included that the resident would…

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

Based on medical record review and interview it was determined that the facility failed to ensure daily weights were obtained as ordered by the physician. This was found to be evident for 1 out of 6 residents (Resident #81) reviewed for unnecessary medications. The findings include: On 5/1/19 review of Resident #81's medical record revealed diagnoses that include, but not limited to, congestive heart failure (CHF), major depressive disorder and anxiety. CHF is when the heart is not pumping adequately enough to remove excess fluid from the body. Further review of the medical record revealed an order, in effect since 1/3/19, for Daily weight in the morning related to Chronic Diastolic (Congestive) Heart Failure. An increase in weight can be the first indicator of fluid overload and may require medication adjustments. Review of the April 2019 Treatment Administration Record (TAR) revealed the order Daily Wts (weights) - CHF every day shift. Staff had documented that the weights were obtained on 26 out of the 30 days in April 2019. Of the other four days: two days were noted to be…

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

Based on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure that therapy recommendations for splinting devices and restorative nursing services were addressed and implemented if needed. This was found to be evident for 1 out of 5 residents (Resident #62) reviewed for positioning and mobility. The findings include: On 4/26/19 review of Resident #62's medical record revealed the resident had functional limitations in range of motion on one side for both upper and lower extremities. Further review of the medical record revealed a care plan addressing activities of daily living which included the following interventions: PT[physical therapy/OT [occupational therapy] evaluation and treatment as per physician orders. No documentation was found in the current active care plan regarding splinting devices or restorative nursing services for this resident. A.) Further review of the medical record revealed the most recent restorative services found in the TASKS [area of electronic health record for geriatric 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.

Based on medical record review and interview it was determined that the facility failed to ensure assessments were completed when residents returned from dialysis treatment and failed to ensure an effective system of communication with the dialysis center. This was found to be evident for 1 out of 1 resident (Resident #31) reviewed for dialysis during the survey. The findings include: Review of Resident #31's medical record revealed the resident goes out of the facility for dialysis treatment 3 times a week. Review of the physician orders revealed orders, in effect since November 2018, for a pre-dialysis assessment and a post-dialysis assessment to be completed every day shift every Monday, Wednesday and Friday. On 4/26/19 at 12:50 PM the Unit Nurse Manager #3 stated that there is a communication book that the resident takes to dialysis with him/her. She went on to report that there is a pre-dialysis form that the nurse's complete and send in the communication book. On 4/26/19 at 1:23 PM Unit Nurse Manager #3 reported that there are orders for pre and post dialysis assessment 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 staff failed to document an accurate overview of the resident during a physician visit. This was evident during 1 of 1 physician records reviewed for Resident #22. The findings include: During a telephone interview with Staff #29 in the presence of the survey team, the Director of Nursing (DON) and Staff #15 on 5/1/19 at 7:00 PM, Staff #29 verbalized that secondary to the plethora of medications that Resident #22 is on he did not feel it was appropriate to put him/her on any additional medications related to the residents noted and documented increased anxiety and hoarding behavior. A review of Staff #29's physician notes from December 2018 to April 2019, revealed that Staff #29 documented Resident #22 as receiving 12 main medications, besides antibiotics and skin creams that were administered in January 2019. A review of the residents Medication Administrator Record (MAR) failed to reveal the administration of those same medications December 2018 through April 2019. Resident #22 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 review of employee files and interview with staff it was determined that the facility failed to ensure that a Geriatric Nursing Assistants (GNA), demonstrated competency in skills and techniques to care for residents. This was found to be for 2 out of 2 GNA's (Staff #24 and #25) hired in the past year and selected for review of competencies. The findings include: 1. Review of the employee file for Staff #24 failed to reveal any competencies. Interview on 4/23/19 with the Human Resources director, Staff #4, confirmed Staff #24 was hired on 3/20/19 as a GNA, according to the corporations qualified hire authorization form. Further review of Staff #24's file on 5/1/19 revealed that she had orientation on 3/21/19 and 3/25/19 according to a schedule given to the survey team by Staff #1. Interview on 5/1/19 at 12:54 PM with Staff #15 revealed that for new staff, even if they are new to the field, will be scheduled for 2 shifts per floor. The Director of Nursing (DON) was also present and stated that the new employee will orient on more than one floor so the preceptor will change…

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 pertinent documentation and interview it was determined that the facility failed to retain the posted daily staffing information. This was found to be evident for the entire facility. The findings include: On 4/22/19 the facility was unable to provide posted staffing documentation for the past week. It was found that the posting was only being recorded on a wipe board on the units, per the Director of Nursing upon interview on 4/22/19.

Based on medical record review and interview with facility staff, it was determined that the facility failed to put interventions in place regarding a resident's diagnosis (Resident #22). The findings include: Surveyor interview with Resident #22 on 4/24/19 at 1:08 PM revealed concerns that some of his/her personal items were missing and that the facility had not attempted to find/replace them. The facility Administrator was interviewed on 5/1/19 about Resident #22's items and he stated that s/he has so much that s/he has his/her own storage shed. The Administrator provided the survey team with an itemized list of items that the facility was keeping track of that the resident was buying since December 2018. Members of the survey team asked to see the items on the list. The storage shed was observed with 2 members of the survey team and staff #27 on 5/1/19 at 4:38 PM. Staff #27 stated that he along with the Administrator and the Activities director all have a key to this storage shed. With the assistance of Staff #27, members of the survey team were unable to locate the specific…

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 provide adequate indications for the usage of an anxiety medication. This was evident for 1 of 5 residents (Resident #88) reviewed for unnecessary medication use. The findings include: Review of the medical record for Resident #88 on 4/29/19 at 3:44 PM revealed diagnoses including anxiety and major depressive disorder. Further review revealed a recent discharge from the hospital. Review of the hospital summary documented under the medication list for the resident to 'STOP' taking previously prescribed anxiety medication. Review of the Resident #88's admission medication orders on 4/1/19 did not include the anxiety medication. On 4/4/19 an order was noted in the computer for the anxiety medication at a dose twice what the resident was taking prior to the hospitalization from .125 mg to .25 mg every 12 hours. Physician note from 4/12/19 document that the family was concerned related to the residents increased sleepiness during the day and recommended that the resident…

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 nursing staff failed to sign off the administration of a narcotic on the Medication Administration Record (MAR) and the Controlled Substances Record consistently. This was evident during the review of 1 of 5 residents (Resident #88) for unnecessary medications. The findings include: 1. Review of the medication administration record (MAR) for Resident #88 on 4/30/19 at 11:31 AM revealed discrepancies for the months of March and April 2019, between his/her MAR and controlled drug receipt/record/disposition form. The purpose of the controlled drug receipt is to consistently count controlled substances or narcotics and to monitor narcotic administration and ensure accountability of all substances and narcotics. According to the MAR, Resident #88's sedative was ordered every 12 hours as needed. On 3/30/19 at 8:46 PM the medication was signed off as administered but there was no corresponding sign-out on the controlled drug log. On 4/17/19 at 9:34 PM and 4/30/19 8:41 AM, the medication was also signed…

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 interview with staff it was determined that the facility failed to arrange a dental appointment for the resident in a timely manner this was true for 1 out of 1 resident (Resident #312) reviewed for dental in the investigative stage of the survey. The Findings Include: During an interview with Resident #312 on 4/24/19 the resident verbalized his/her main concern was tooth pain. The resident reported that his/her tooth was very painful. The resident further reported that staff was aware of the tooth pain. On 4/26/19 Resident #312's medical records were reviewed and revealed that the resident was admitted to the facility 3/30/19 for respite care (temporary institutional care of a sick, elderly, or disabled person, providing relief for their usual caregiver) and with diagnosis which included seizure disorder. Review of the nursing note revealed a note written on 4/1/19 which stated: Resident complained of extreme tooth pain rated at greater than 10. Resident states he/she sustained damage to her/his teeth during a seizure. Resident was ordered pain…

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

Based on review of employee files and interview with facility staff it was determined that the facility failed to employee staff with active professional licenses relevant to their hired job descriptions. This was evident during the review of 2 of 2 employee files, (Staff #24 and #25) The findings include: 1. Review of the employee file for Staff #25 on 4/22/19 at 1:47 PM revealed the employee was hired for the position of a geriatric nursing assistant (GNA) with a start date of 4/17/19. Review of the facility's case status review packet under professional licensing, the status was marked with an 'X.' Further review of the employee's licensure status as a geriatric nursing assistant (GNA), it was revealed as suspended. According to the employees file provided by the facility, documentation from the Board of Nursing reported that the license was suspended as: subject violated rules set forth by the Board. Review of Staff #25's punch card revealed that the employee worked on 4/17/19, 4/19/19 and was scheduled to work again the evening of 4/22/19 independently with residents according…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews it was determined that the facility failed to: 1) ensure reports from outside providers were available in the medical record for review by other health care providers; 2.) failed to ensure certifications of medical ineffectiveness and or end stage/terminal condition were completed and on the chart for a resident whose surrogate decision maker made the decision for the resident to have a No CPR (cardiopulmonary resuscitation) order; 3.) failed to ensure physician notes were maintained on the medical record for other health care providers to review;. 4.) failed to have the correct Maryland Order for Life Sustaining Treatment (MOLST), active on a resident's chart.; 5.) failed to have completed labs on the chart. This was found to be evident for 5 out of 27 residents (Resident #90, #23, #81, #30 ,#88) reviewed during the investigative stage of the survey. The findings include: 1. On [DATE] the Resident #90 reported having had a sleep study about the first of the month.…

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

Based on review of Quality Assurance (QA) sign in sheets and interview it was determined that the facility failed to ensure the QA committee met at least quarterly. This was found to be evident for the first quarter of 2018 and has the potential to affect all the residents. The findings include: On 5/1/19 review of the Quality Assessment Assurance Committee sign in sheets for 2018 failed to reveal any documentation of a meeting in January, February, March, April or May of 2018. On 5/1/19 at 7:47 PM the Director of Nursing reported that he was unable to provide sign in sheets for the QA meetings for January thru May 2018.

Based on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and procedures by ensuring that a resident room was kept clean and dry and free of drainage. This was evident for 1 (Resident #81) reviewed during the facility's annual survey. The findings include: An observation was made of Resident #81 on 4/22/19 at 11:30 AM. The resident was sitting in a wheelchair in his/her room and there was a large wet puddle on the floor underneath the wheelchair. On the same date at 12:10 PM GNA, Staff #9 was made aware and went into the room to assist the resident. The GNA stated the resident has edema (swelling) to both legs and seepage occurs occasionally. In a interview with the Unit Director (UD), Staff #12 on 4/22/19 at 12:20 PM s/he was made aware of the resident sitting in his/her wheelchair with a wet puddle on the floor underneath him/her. The UD stated the resident has bilateral edema to the legs. Another observation was made of Resident #81 on 4/26/19 at 10:45 AM. The resident was sitting in a wheelchair 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.