Westminster Rehabilitation and Wellness Center

Based on observation, record review, and interview, the facility failed to ensure implementation of physician-ordered pressure-relieving interventions and proper functioning of a pressure-reducing device for 1(Resident #47) of 1 residents reviewed for pressure ulcer care.The findings include: On 4/28/26 at 11:05 AM, during the surveyor's observation of the unit, Resident #47 motioned for the surveyor to enter their room from the hallway.Upon entering, the resident's call bell was not within reach and could not be located.On 4/28/26 at 11:08 AM, the surveyor observed that Resident #47 was lying on a pressure-reducing air mattress that was actively alarming, with a weight setting of 1000 pounds. At that time, Resident #47 stated to the surveyor that they were in pain. The mattress was deflated, and the resident appeared to be lying on the bed frame.Due to the absence of an accessible call bell, the surveyor activated the empty bed call bell to alert staff.On 4/28/26 at 11:18 AM, Staff #6, a Registered Nurse, entered the room in response to the call. The surveyor informed Staff #6 that…

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

Based on interviews and record reviews, it was determined that the facility failed to ensure that ordered medications were available for dispensing to residents. This was evident for 1 (Resident #11) of 2 residents reviewed for pain management.The findings include:On 4/28/26 at 4:00 PM, the surveyor interviewed Resident #11, who reported having multiple spinal conditions that cause significant pain. When asked whether the facility effectively manages their pain, the resident stated that staff are generally timely with medication administration; however, there is an ongoing issue with the pharmacy resulting in medications not being available at times. The resident stated, I go crazy about the medications because they use a pharmacy that is always running out of medications. They further reported that it sometimes takes several days for medications to become available.On 4/30/26 at 1:37 PM, the surveyor conducted a record review of the Resident #11's February, March, and April 2026 Medication Administration Records (MARs) and identified multiple gaps in documentation of medication…

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

Based on record review and interviews, it was determined that the facility failed to ensure that physicians provide a clinical rationale for not implementing pharmacist recommendations. This was evident for 1 (Resident #113) of 5 residents reviewed for unnecessary medications.The findings include:A pharmacist medication review (Medication Regimen Review or MRR) is a monthly safety evaluation required by federal regulation for nursing home residents. It involves a comprehensive review of a resident's medications by a licensed pharmacist to ensure each medication is necessary, effective, and free from unnecessary risk. When a pharmacist identifies potential concerns, recommendations are made to the attending physician for review and consideration. Federal regulations require that when a physician does not accept or implement these recommendations, a documented clinical rationale must be provided to support that decision.On 4/29/26 at 3:24 PM, the surveyor performed a record review of Resident #113's pharmacy recommendations from January 2026 through April 2026 and identified the…

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

Based on observations, record review, and interviews, it was determined that the facility failed to serve residents meals that reflected their preferences. This was evident in one out of two kitchen observations during the survey.The findings include:During an observation of the facility's Lunch tray line service on 4/30/26 at 1.15 PM, the surveyor requested a test tray as the last tray was being prepared. The tray included a meal slip for Resident #75, indicating that the Resident was on a regular diet and was to receive double portions of the entree. The Resident was to be served Italian sausage, 1/2 cup of sauteed spinach with garlic, 1/2 cup of Parmesan noodles, 1 buttered dinner roll, margarine, spiced peaches, 4 oz yogurt, and 8 oz fruit punch.An inspection of the tray revealed Italian sausage, sauteed spinach, Parmesan noodles, buttered dinner roll, margarine, spiced peaches, and 8 oz of fruit punch. However, the kitchen failed to provide Resident #75 the 4-oz yogurt as indicated on the meal slip. A record review later that day for Resident #75 contained a dietitian's note…

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

Based on resident interviews, observation, and staff interviews, it was determined that the facility failed to serve residents meals that were appetizing in appearance and at the appropriate temperature. This was evident for 1 of 2 kitchen observations. The findings include:During the initial screening of the survey on 4/28/26, Residents #26, #37, #10, #82, and #84 reported that the facility's food was served cold and tasted bland and terrible.An observation of the kitchen on 4/30/26 at 11:54 AM revealed that Staff #11 (Cook) was preparing food for lunch. An inspection of the steam table revealed that the cook had begun adding items before the surveyor arrived. Sausage and dinner rolls were on the steam table, and during the observation, spinach and parmesan noodles were added. Before preparing the trays to be sent to the units, staff #36 failed to check the temperatures of the food items on the steam table to determine the holding temperatures of the hot foods.During continued observation on 4/30/26 at 1.15 PM, the surveyor requested a test tray as the last tray was being prepared.…

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 record review, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 of 2 observations of the facility's kitchen during the recertification survey.The findings include:An initial tour of the facility's kitchen with the staff #12, dietary manager, on 4/28/26 at 8:52 AM revealed the following:- An observation of the walk-in freezer noted 3 slices of chicken patty in a zip-lock bag, with no label of when it was opened or the use-by date. Staff said, I got you, and added, I will just trash it.- An Observation of the facility's walk-in refrigerator revealed the following:-3 slices of bologna in a zip-lock bag; it had no label indicating when it was opened or its use-by date.-chunks of pineapple in a container with a label that stated, use by 4/22. Staff indicated that the labeling was a mistake. He said the date on there was the date it was prepared; however, it lacked an expiration date.-Butter scotch pudding labeled use by 4/25. Staff said it was a mistake and that the date was the opening…

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 it was determined that the facility failed to ensure staff maintained physician ordered enhanced barrier precautions when providing care. This was found to be evident for one (Resident #7) out of one resident reviewed for tube feeding.The findings include: Review of Resident #7's medical record revealed the resident received medications and feedings via a feeding tube. A feeding tube refers to a medical device used to provide liquid nourishment, fluids and medications by bypassing oral (by mouth) intake. Feeding tubes can also be called enteral tubes, PEG tubes or g-tubes. Review of the facility's policy for Enhanced Barrier Precautions (EBP) revealed: EBP refers to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs hand hygiene, as well as targeted gown and glove use during high contact resident care activities. These activities include, but are not limited to, accessing/use of a feeding tube.On 5/1/26 at 8:33 AM surveyor observed Nurse #13 access the resident's…

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

Based on observation and interview, the facility failed to ensure that a resident call system was within reach and readily accessible to meet resident needs for 1 (Resident #47) of 1 resident reviewed for call bell accessibility.The findings include: On 4/28/26 at 11:05 AM, observation on the unit revealed Resident #47 motioned for the surveyor to enter their room from the hallway.Upon entering, the resident's call bell was not within reach and could not be located. Resident #47 stated they were in pain.Due to the absence of an accessible call bell, the surveyor activated the empty bed call bell to alert staff.On 4/28/26 at 11:18 AM, Staff #6, a Registered Nurse, entered the room in response to the call. The surveyor informed Staff #6 that Resident #47 had motioned for assistance, and the resident's call bell could not be located.On 4/28/26 at 11:20 AM, Staff #6 located the resident's call bell behind the head of the bed, retrieved it, and secured it to the resident's blanket, making it accessible. Staff #6 acknowledged the surveyor's concern related to Resident #47's call bell…

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

Based on administrative record review and staff interview it was determined that the facility staff failed to ensure that a resident was free of abuse while in the care of a Geriatric Nursing Assistant (GNA). This was evident for 1 (#2) of 1 residents reviewed for abuse. The findings include: On 2/11/26 at 12:06 PM, a review of facility reported incident, #2618494, revealed the facility had substantiated physical abuse based on resident and staff interviews. The facility investigation revealed on 9/11/25 after dinner & before 11:00 PM, during incontinence care, Resident #2 was slapped on his/her buttocks 2 times by Staff #1, Geriatric Nursing Assistant (GNA). The facility investigation documented the allegation of physical abuse was verified by the victim's statements, the repeated interviews that produced a consistent recounting of the incident, and the police confirmed the witness, Staff #2, GNA was involved to the extent that matched the alleged victim's consistent statements. As a result of the facility's investigation, Resident #1, GNA was terminated for his/her actions 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 administrative record review and staff interviews, it was determined that the facility staff failed to immediately report allegations of abuse to the facility administration and the state agency and failed to report the results of their investigation of an alleged incident to the State Survey Agency within 5 working days of the incident. This was evident for 1 (#2) of 1 resident reviewed for abuse. The findings include: On 2/11/26 at 12:06 PM, a review of the facility's investigation documentation for facility reported incident, #2618494 was conducted and alleged on 9/11/25, sometime after dinner and before 11:00 PM, Resident #2 was abused by Staff #1, Geriatric Nursing Assistant (GNA), and the abuse was witnessed by GNA #2, GNA. Following the incident, GNA #1 did not report the abuse and GNA #2, failed to notify the facility's administration of the witnessed abuse. The facility's self-report documented the alleged abuse was reported by Resident #2 to GNA #6 on 9/13/25 between 2:30 PM and 3:00 PM and GNA #6 then reported the abuse allegation to the facility's…

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

Based on medical record review, facility documentation review and interview it was determined the facility failed to maintain an effective grievance system as evidenced by the failure to resolve a complaint regarding missing clothing belonging to a resident (Resident #6). This was evident for 1 of 3 residents reviewed for grievances during this complaint survey. The findings include:Review of complaint 326588 on 8/12/25 revealed a concern related to Resident #6's missing clothes and the Resident's clothing not being returned from laundry. Medical record review on 8/12/25 revealed Resident #6 was admitted to the facility in July 2022. Further review of Resident #6's medical record revealed the facility staff assessed the Resident on 8/3/25 to have a BIMS (Brief Interview for Mental Status) of 14 out of 15, indicating the Resident's cognitive function is intact. During interview with Resident #6 on 8/12/25 at 11:22 AM, the Resident stated he/she is missing 4 pairs of sweatpants: 1 blue, 1 black and 2 grey. The Resident stated he/she has told the facility staff, and they had not done…

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 facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of misappropriation of property were thoroughly investigated. This was evident for 1 (#2) of 3 residents reviewed for facility reported incidents during a complaint survey.The findings include:On 8/13/25 at 7:37 AM a review of facility reported incident 326591 was conducted and revealed Resident #2 alleged that on 6/5/25 someone broke into Resident #2's locked nightstand drawer and stole ninety dollars. The facility report documented that Resident #2 stated, I think it happened last night, 6/1/25, unsure of time, did not notice the money missing and drawer broken until this morning. Review of the facility's investigation revealed a written statement from the Director of Nursing (DON) that documented Resident #2 thought that it happened the previous night as the resident was up late watching TV in the dining room, however there was not an exact time. The facility investigation revealed that (5) staff members worked the night shift, 11:00…

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

Based on record review and staff interview it was determined that the facility failed to meet professional standards of practice as evidenced by licensed nursing staff signing off that a medication was administered when the medication had not yet been delivered to the facility. This was evident for 1 (#1) of 3 residents reviewed for pharmacy services. The findings include:According to the National Library of Medicine, the sixth right of medication administration, correct documentation, should be done immediately after the medication is administered. Signing off on a medication that was not given is a violation of the principle as the documentation does not reflect the actual care provided.On 8/12/25 at 11:34 AM a review of Resident #1's medical record revealed Resident #1 was admitted to the facility in May 2024 with diagnoses that included, but were not limited to, cerebral infarction with hemiplegia and hemiparesis, aphasia, generalized anxiety disorder, bipolar disorder, and major depressive disorder.Review of a 7/17/25 at 15:20 (3:20 PM) SBAR (change in condition) note…

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 medical provider failed to review the pain medication orders for a resident (Resident #4). This was evident for 1 out of 3 residents selected for review during a complaint survey. The findings include: A review of a complaint was conducted on [DATE] regarding the facility stopping Resident #4's Oxycodone in [DATE]. Oxycodone is a narcotic medication used to treat moderate to severe pain. Review of Resident #4's medical record on [DATE] revealed the Resident was admitted to the facility in [DATE] with a diagnosis of chronic pain due to trauma. Review of the Resident's physician orders on admission revealed the Resident was ordered Oxycodone 15 mg every 4 hours as needed for pain. Further review of the Resident's medical record revealed the Resident was followed by the Physical Medicine and Rehabilitation Nurse Practitioner (Staff #15) for pain management. Review of Staff #15's medication orders revealed Staff #15 decreased the Oxycodone 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 provide physician ordered medications timely to meet the needs of the residents. This was evident for 1 (#1) of 3 residents reviewed for facility reported incidents during a complaint survey.The findings include:On 8/12/25 at 11:34 AM a review of Resident #1's medical record revealed Resident #1 was admitted to the facility in May 2024 with diagnoses that included, but were not limited to, cerebral infarction with hemiplegia and hemiparesis, aphasia, generalized anxiety disorder, bipolar disorder, and major depressive disorder.Review of a 7/17/25 at 15:20 (3:20 PM) SBAR (change in condition) note documented that Resident #1's left eye was noted with redness, like a blood vessel had broken. A new order was given to start the resident on an eye drop, Polyethylene glycol.A 7/17/25 at 21:09 (9:09 PM) eMar (electronic Medication Administration Record note) documented, Polyethyl Glycol-Propyl Glycol Gel 0.4-0.3%; Instill 1 drop in left eye two times a day for protection for bloodshot/dry OS (left…

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 failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#1) of 3 residents reviewed for facility reported incidents during a complaint survey. The findings include:A medical record is the official documentation of 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.On 8/12/25 at 11:34 AM a review of Resident #1's medical record revealed Resident #1 was admitted to the facility in May 2024 with diagnoses that included, but were not limited to, cerebral infarction with hemiplegia and hemiparesis, aphasia, generalized anxiety disorder, bipolar disorder, and major depressive disorder.Review of a 7/17/25 at 15:20 (3:20 PM) SBAR (change in condition) note documented that Resident #1's left eye was noted with redness, like a blood vessel had broken. A…

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

Based on record review, interview, and facility policy review, the facility failed to follow the physician's orders for 1 (Resident #1) of 3 residents reviewed for medications. Specifically, the facility failed to discontinue Resident #1's tramadol, (pain medication) as ordered by the physician, on 12/13/2024 when oxycodone (opioid pain medication) arrived at the facility. The facility administered both medications to Resident #1 on the morning of 12/14/2024. Findings included: A facility policy titled, Medication Administration, dated 12/02/2024, indicated, 1. General Procedures: a. Administer medication only as prescribed by the provider. An admission Record revealed the facility admitted the resident with diagnoses that included acute embolism and thrombosis of the left femoral vein, neurofibromatosis, unspecified intellectual disabilities, pain in the right and left foot, and polyneuropathy. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated 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 review of facility-reported investigation records and interview with staff, it was determined the facility staff failed to report an allegation of suspected resident abuse to the state agency in a timely manner. This was evident for 1 resident (Resident #102) out of 3 reported incidents by the facility reviewed during the survey. The findings include: A review of facility reported incident MD00207413 was started on 10/09/2024 at 12:22 PM. The facility incident report indicated the following: Alleged abuse incident occurred in the resident's room at about 11:45 AM of 07/08/24. The administrator and Law enforcement were notified on the same day and the initial report was sent to the state agency at 3:47 PM of the same day. At 2:32 PM on 10/09/2024, surveyor reviewed a copy of the facility's policies and standard procedures on reporting incidents and facility response, and it revealed that allegations involving abuse should be reported to the state agency within 2 hours, aligning with the federal requirement. On 10/10/2024 at 12:49 PM, in an interview with the Director of…

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

Based on record review and interview it was determined that the facility staff failed to complete a thorough investigation of an allegation of misappropriation of property and failed to investigation an allegation of verbal abuse. This deficient practice was evident in 2 (Resident #31 & #49) of 9 facility reported incidents reviewed during the survey. The findings include: 1. On 10/16/24 at 1:29 pm during a review the facility's investigation of MD00207401 it revealed on 05/03/24 during 7:00 am-3:00 pm shift, a blister pack of Resident #49's Oxycodone was missing from Licensed Practical Nurse (LPN) #24's medication cart located on Station #3. Further review of the investigation revealed a statement from LPN #24. Review of the staffing sheets revealed there was no copy of the staffing sheet to include the nurse who completed the narcotic count with LPN #24 and no evidence of an interview of nurse who completed the narcotic count before the medication became missing. On 10/16/24 at 2:25 pm during an interview with LPN #24 he/she confirmed the missing narcotics were taken from 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 interviews with residents, review of medical records, and interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents. This was evident for 1 (#45) of 7 residents reviewed for baseline care plans during the survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP as well as a list of the resident's current medications must be given to each resident and his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. Resident #45 was interviewed on 10/08/24 at 12:44 PM. During the interview, when asked if he/she received a BLCP that included a summary of their medications within 48 hours 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 record review and interview it was determined that the facility staff failed to initiate person centered care plan for mobility and wound care. This deficient practice was evidenced in 1 (#67) of 4 resident records reviewed for care plans. The findings include: On 10/17/24 at 11:27 am a review of Resident #67's electronic medical record revealed the resident had two pressure ulcers and one was facility acquired. A review of the care plan revealed there were no interventions in place when the resident refused to be turned or repositioned. Further review of the resident's care plans revealed Resident #67 did not have a person-centered care plan related to skin integrity. The care plan did not include the resident's wound care and interventions specific to the resident's care. On 10/18/24 at 1:33 pm during an interview with Director of Nursing #2 he/she confirmed Resident #67 did not have patient centered care plans for mobility and skin integrity and indicated going forward the resident's care plans would have specific orders with the interventions. The staff were educated 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 reviews and interviews it was determined that the facility failed to ensure that a dependent resident's personal hygiene needs were adequately met. This was evident for 1 (Resident #2) of 23 residents reviewed during the survey process. The findings include: Activities of daily living is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. The task assessment record (TAR) is a electronic form utilized by nursing staff to document the activities of daily living of the residents. On 10.10.24 at 10:30 AM review of the MD00207907 and medical records involving Resident #2's Activities of daily living revealed the resident is a vulnerable adult that required maximum 2-person assistance with activities of daily living based on the care plan initiated 03.02.22 secondary to trauma to below the knee amputation, morbid obesity, and impaired mobility. Continued review revealed that on 08.14.24 the facility failed to document that staff provided assistance with the resident's personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility staff failed to notify the family of a deceased resident that money was still in their account. This deficient practice was evidenced in 1 (#113) of 2 resident accounts reviewed during the survey. The findings include: On [DATE] at 10:40 am the surveyor reviewed the account balances of all the residents' funds that were managed by the facility. Review of the Trial Balance sheet revealed Resident #113 expired on [DATE]. The surveyor asked Business Office Manager #33 had the family been made aware of the resident's account balance. Business Office Manager #33 verbalized a letter was sent to the family the previous day which was past the 30-day allotted timeframe for notification.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with staff, it was determined that the facility staff failed to protect the privacy of residents' medical information. This was found to be evident for 1 (#70) of 45 residents reviewed during the survey. The findings include: On 10/16/24 at 9:40 AM as the surveyor walked down the hallway (approximately 1 minute) approaching the medication cart at the end of the hallway, the surveyor did not observe a nurse by the medication cart which was across from room [ROOM NUMBER]. Furthermore, the surveyor observed a laptop computer on top of the medication cart that was unlocked and open with patient information on it. The screen displayed Resident #70's medication administration record (MAR) which displayed what medications Resident #70 was prescribed. Approximately 1 minute later, Licensed Practical Nurse (LPN #36) exited the room (#242). She approached the cart and clicked the mouse so the laptop screen changed from having Resident #70's MAR visible on the screen to showing,…

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

Based on interviews, observations, and medical records reviews, it was determined that the facility failed to: 1.) perform and/or document that appropriate revisions to care plan goals and interventions as resident care needs changed over time. This was evident for 1 (Resident #2) of 45 resident care plans reviewed during the facility's survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. On 10/09/24 at 09:41 AM a surveyor met with the resident #2 in his/her room and discussed the content of intake MD00207907 regarding basic clinical services related to activities of daily living (ADLs). Resident #2 stated that the staff took away his/her commode chair because she/he fell once while trying to get back in bed after using the commode chair. The resident stated he/she would like to be able to use the commode chair in order to decrease the chances of sacral wounds and to increase mobility. This resident stated that he/she was reluctant to get out bed to…

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

Based on observations and interviews with facility staff it was determined the facility failed to adhere to professional standards of practice by failing to: 1.) ensure that controlled medications (Narcotics) were signed off by the Licensed Practical Nurse upon removing the medication from the narcotic drawer for 3 residents (Residents # 41, #45, and #107) during a random narcotic reconciliation observation; and 2.) ensure the safety and integrity of narcotic medications blister packs for Resident Resident # 67 and Resident # 78; and 3.) ensure that two nurses sign the narcotic sheet during change of shift to verify the narcotic count was complete. This was found to be evident during the facility's survey. Findings include: 1. A random narcotic medication reconciliation observation was conducted with the Licensed Practical Nurse upon (LPN) # 12 on 10/16/24 at 10:15 AM. Review of a medication blister pack for Resident # 41 was labeled Lorazepam 0.5 mg which had 10 pills in the blister pack. The corresponding narcotic control form for Resident #41 indicated Lorazepam 0.5 mg with 11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with staff, it was determined the facility staff failed to ensure medications were secured as evidenced by an unlocked and unattended medication cart. This was found to be evident for 1 of 7 medication carts reviewed during the survey. The findings include: On 10/16/24 at 9:40 AM as the surveyor walked down the hallway (approximately 1 minute) approaching the medication cart at the end of the hallway, the surveyor did not observe a nurse by the medication cart which was across from room [ROOM NUMBER]. The surveyor approached and stopped next to the medication cart and noted the silver button that locks the medication cart was protruding out, in the unlocked position. Approximately 1 minute later, Licensed Practical Nurse (LPN #36) exited the room (#242). She approached the cart and pushed the silver button on the top right hand side of the medication cart which depressed it into the locked position. When asked if the medication cart was left unattended and unlocked,…

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 staff failed to maintain infection control practices as evidenced by an uncapped foley catheter drainage bag in a resident bathroom, two unlabeled urinals without lids were in a shared bathroom along with a brown matter on the commode of a shared bathroom. This deficient practice was discovered during the survey. The findings include: On 10/08/24 at 7:47 am during observation rounds on Unit 3 the surveyor observed an uncapped foley catheter drainage bag hanging on the handle of the commode in room [ROOM NUMBER]. Geriatric Nursing Assistant #14 confirmed the surveyor's findings. At 7:56 am the surveyor observed two unlabeled urinals without lids hanging over the commode in the shared bathroom between Rooms 105-106. At 8:04 am the surveyor observed brown matter on the shared bathroom commode located between Rooms 107-108. On 10/15/24 at 1:53 pm during an interview with Infection Prevention Nurse #7 he/she verbalized the urinals are not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility failed to: 1) revise and update a comprehensive care plan within 7 days after completing the comprehensive assessments, and 2) have care plan meetings with residents and/or their representatives. This was evident for 5 (Resident #61, #75, #87, #88, and #110) of 41 residents reviewed during the recertification survey. The findings include: A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Facility staff must develop the comprehensive care plan within seven days of completing the comprehensive assessment (Admission, Annual or Significant Change in Status) and review and revise the care plan after each evaluation. After each assessment means that after each assessment, it is known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS). Minimum Data Set: The Minimum Data Set (MDS) is part of the federally mandated…

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, staff interviews and a complaint, it was determined that the facility failed to: 1) have a process in place to address and review medical orders pending provider signature; 2) provide timely care for residents who experienced a change in condition; and 3) timely arrange for a resident to go for their 2-weeks follow up (F/u) post op visit. This was evident for 4 of 41 residents (Resident #46, #109 and #110, #107) reviewed during recertification survey The findings include: 1) On 4/4/24 at 10:02AM the surveyor conducted a review of the medications for Resident #46. Upon review of the resident's April 2024 Medication Administration Record (MAR) it was revealed that on 4/1/24 the following medication had been documented as administered: methylprednisolone sodium succinate injection. Review of the medical order dated 4/1/24 indicated the medication was a one-time dose. Further review of the April 2024 MAR revealed a second order dated 3/31/24 for the one-time dose of the medication,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the physician/Certified Registered Nurse Practitioner (CRNP) progress notes were not written, signed and timely present in the resident medical records. This was evident for 2 (Residents #46, and #106) of 41 residents reviewed during the survey. The findings include. 1) On 4/4/24 at 10:02AM the surveyor conducted a review of the medication orders for Resident #46. During this review, it was noted the resident was currently receiving 15mg of the following psychiatric medication: escitalopram. On 4/4/24 at 10:02AM the surveyor reviewed the most recent psychiatric note present in the resident's medical record which was dated 3/15/24. The surveyor noted that the visit date was 3/15/24, however, the note had not been uploaded to the resident's medical record until 3/21/24, approximately, seven days after the visit was dated as having occurred. Review of this note indicated a recommendation made by Staff #38, Psychiatric Certified Registered…

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

Based on record review and interview it was determined that the facility failed to treat residents with respect and dignity. This was evident for 1 facility reported incident (MD00204591) of 7 facility reported incidents reviewed during the recertification survey. The findings include: On 4/15/24 at 9:45 AM a review of the facility reported incident MD00204591 revealed an allegation that Resident #32 was treated roughly by a Geriatric Nursing Assistant (GNA #8). On 4/15/24 at 11:05 am an interview with Resident #32 was conducted. The resident described an incident where GNA #8 dragged the resident backwards on a shower chair through the hallway from the resident's room to the shower room and then back to the resident's room. The resident stated GNA #8 could not pull him/her forward because the resident's feet were dragging on the floor and in the way. On 4/15/24 at 3:54 PM during an interview with the Nursing Home Administrator (NHA), the facility's final report of the incident was reviewed. It revealed an action plan for GNA #8 to be instructed on dignity and transfers and given a…

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

Based on a complaint, reviews of medical records, and staff interview, it was determined that facility staff failed to notify a resident's representative party and physician when a resident had a change in diet order and a new prescribed medication. This was evident for 1 (Resident #110) of 41 residents reviewed during the survey. The findings include: On 4/10/24 at 9:15 AM, a complaint MD00202974 related to Resident #110 was reviewed. The complaint alleged the staff failed to notify Resident #110's loved one about his/her diet order changes and a new prescribed medication. During a phone interview with Resident #110' s loved one on 4/10/24 at 10:20 AM, he/she reported, when the facility staff called me on 2/21/24, they told me [Resident #110] was on puree diet. I never heard about why and when it started. Also, when [Resident #110] transferred to the hospital on 2/23/24, he/she was diagnosed with pneumonia. The facility kept saying he/she had been taking cough medication. But I never heard about coughing and medication. A review of Resident #110's medical record on 4/10/24 at 10:50…

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 facility records and interview with facility staff, it was determined that facility staff failed to ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #108) of 5 residents reviewed for Abuse during the survey. The findings include: On 4/08/24 at 7:41 AM, the surveyor investigated the facility-reported incident, MD00201978. The facility self-report documented that Resident #108 reported two staff members tossed him/her to bed on 1/27/24 during the evening shift (3 PM to 11 PM). The review of the facility's investigation revealed that they had two written statements from two Geriatric Nurse Aides' (GNAs #28 and #29), who worked on 1/26/24, and one Licensed Practical Nurse's (LPN #27) statement written on 1/29/24 (without indicating they cared the resident on 1/26/24 or not). The facility investigation packet also included an assignment sheet for the night shift on 1/26/24. However, GNA #28, #29, and LPN #27 were not listed on the sheet. During an interview with the Nursing Home Administrator (NHA) on 4/08/24 at 9:00…

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

Based on observation, interview and record review it was determined that the facility failed to provide dental services to meet residents' needs. This was evident for 1 of 2 (Resident #17) reviewed for dental during the survey. The findings include: On 4/01/24 at 10:08 AM an observation and interview with Resident #17 was conducted. The resident was observed to have only bottom dentures and had no natural upper teeth. Resident #17 explained that his/her upper dentures had been lost a few months ago and had not been replaced, and although a care plan meeting was held last week when he/she was told a dentist would come to the facility to do the needed impressions, there had been no follow up to date. On 4/04/24 at 1:38 PM a review of Resident #17's medical record revealed a care plan problem for poor fitting dentures. No dental care notes were found in the resident's record. The surveyor requested all documentation related to the resident's dental care. On 4/05/24 at 1:55 PM another review of Resident #17's record was conducted, and no dental notes were found in the clinical progress…

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

Based on record review and interviews, it was determined the facility failed to: 1) adequately document certifications of incapacity and ensure accuracy of the Maryland Medical orders for life sustaining treatment (MOLST) form (Resident #15), and 2) ensure pertinent information regarding surrogacy/guardianship disputes were documented in the medical records (Resident #101). This was evident for 2 of 41 residents reviewed during the recertification survey. The findings Include 1. On 4/2/24 at 10:00AM the surveyor reviewed Resident #15's advanced directives document in which they had identified their selection of a primary health care agent. On 4/2/24 at 10:00AM the surveyor reviewed Resident #15's MOLST form dated 2/19/24 which indicated the patient had a guardian. No documentation could be found in the medical record regarding a guardian for the resident. On 4/2/24 at 10:00 AM the surveyor reviewed a Certification of Incapacity form dated 11/11/22 located on Resident #15's paper medical record, and noted Part 1 of the form requiring identifying information was left blank. 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 interviews, observation, and record review, it was determined that the facility administration failed to provide adequate oversight activities for the facility to ensure that resources were used effectively to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards. This was evidenced by failing to: 1) ensure that the facility had sufficient staff to care residents' needs, 2) ensure that the facility's nursing staff was competent and had the necessary skill sets and training to provide nursing and related services; and 3) ensure that the facility conducted thorough investigations of self-reported incidents. This was evident during the recertification survey and had the potential to affect all residents. The findings include: 1) Surveyors conducted an off-hour visit on Sunday, 8/27/23, at 9 PM. During the visit, surveyors had interviews with four staff who complained about the lack of nursing staff: a). GNA #43 stated that if staff called out, they would work short-staffed and that this would impact resident care, 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 interview and record review it was determined the facility failed to report allegations of abuse or injuries of unknown origin within required timelines or to all required agencies. This was evident for 7 (#22, #69, #74, #99, #109, #151, and #154) of 19 residents reviewed for abuse during the annual survey. The finding include: Incidents of injuries of unknown origin and allegations of abuse are required to be reported to State Authorities within 2 hours of serious bodily harm, and within 24 hours for all others. On 8/16/2023 at 10:00 AM, surveyors requested from the Nursing Home Administrator (NHA) all documentation of the investigations related to the facility reported incidents (FRIs) that were sent to OHCQ. 1) On 8/22/2023 at 10:25 AM, review of the investigation record of a Facility Reported Incident (FRI), MD00187816, revealed that on 1/15/2023 staff observed Resident #74 with some redness and swelling to his/her right upper and lower eyelid with no open areas. Review of Resident #74's medical record on 8/22/2023 at 12:26 PM revealed the following progress notes by…

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

Based on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, neglect, misappropriation of resident property, and injuries of an unknown source. This was evident for 7 (#17, #34, #46, #62, #66, #69, and #149) of 19 residents reviewed for abuse, neglect, misappropriation of resident property, and injuries of an unknown source during this recertification survey. The findings include: On 8/16/2023 at 10:00 AM, surveyors requested from the Nursing Home Administrator (NHA) all documentation of the investigations related to the facility-reported incidents (FRIs) that were sent to the Office of Health Care Quality (OHCQ). 1) Facility reported incident MD00186092 was reviewed on 8/18/23 at 2:41 PM. The facility reported that at approximately 4:55 PM on 11/27/22 Resident #17's [visitor] arrived and immediately started yelling at and using profanity toward the resident. A staff member, identified in the report, as the writer, intervened to protect the resident and the [visitor] left. The report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#34 and #78) of 5 residents reviewed for Respiratory Care, 1 (#121) of 4 residents reviewed for communication, and 1 (#101) of 2 residents reviewed for dementia care. The findings include: The Minimum Data Set (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. Cognitive ability is documented In Section C of the MDS using the Brief Interview for Mental Status (BIMS) assessment tool. The BIMS questions ask the resident what the year and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff it was determined the facility staff 1) failed to ensure resident care plans were reviewed and revised by the interdisciplinary team after each assessment and revised as changes in treatment occur; and 2) failed to have care plan meetings with a resident and/or resident representative. This was evident for 4 (#34, #78, and #85, #66) of 5 residents reviewed for Respiratory Care, 3 (#62, #9, #77) of 4 residents reviewed for care planning; and 1 (#74) of 9 residents reviewed for accidents during this 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) During an observation and interview on 8/17/23 at 11:35 AM Resident #78 was observed sitting in a wheelchair in his/her room. An oxygen concentrator (a machine that concentrates oxygen from the air in the room) was observed in the room. The resident indicated that he/she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint, medical record review, and interview, it was determined that the facility failed to ensure staff followed physician orders. This was evident for 6 (#2, #3, #34, #92, #137, and #142) of 15 residents reviewed for quality of care during the recertification/complaint survey. The findings include: 1a) On 8/16/2023 at 10:36 AM during an interview with Resident #92, the resident stated that s/he had not gone for an outside doctor's appointment for over a year. Resident #92 stated that s/he has a pacemaker, AFIB, and has not physically seen a heart doctor for over 1.5 years. The resident stated that s/he has cataracts and has not seen an eye doctor, and a colonoscopy was scheduled for last June 2022 but the appointment was canceled and has not been rescheduled since. Resident #92 added that they had cervical spine surgery on 3/6/2022 but one-year follow up appointment with the neurosurgeon was not made: They say its's because of transportation. On 9/13/2023 at 11:18 AM, an interview was completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, family and staff interview, documentation review, observation, and review of Resident Council meeting minutes, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 9 (#30, #34, #42, #46, #78, #85, #92, #96, and #120) of 22 Residents' and Residents' Representative interview and 6 (GNA #43, #53, #63, and Staff #35, #52, #54) of 13 Staff's interviews. The findings include: 1) During this survey 7 resident and 2 resident representative interviews were conducted: a. On 8/16/23 at 11:09 AM Resident #92 stated the facility was short staffed on all three shifts, the Geriatric Nursing Assistants (GNAs) complained that they had 15-24 residents to take care of. The resident also stated he/she was changed only once a shift, and his/her call light was sometimes on for hours. b. On 8/17/23 at 10:22 AM Resident #96 said that there were days when his/her dressings were not changed because they said they had an admission and 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.

Based on record review and interviews it was determined that the facility failed to assure that all nursing staff had competency evaluations. This was evident for 5 (RN #42, GNA #43, GNA #57, GNA #58, and GNA #59) of 5 randomly selected nursing staff reviewed for competencies. The findings include: Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. A review of staff records on 9/01/23 at 10:29 AM revealed the following: 1. Registered Nurse (RN) #42 was hired in September 2022. No competency evaluation was found for RN #42. 2. Geriatric Nursing Assistant (GNA) #43 was hired in May 2023. No competency evaluation was found for GNA #43. 3. GNA Staff #57 was hired in March 2018. No competency evaluation found. 4. GNA #58 was hired in June 2023. No competency evaluation was found for GNA #58. 5. GNA #59 was hired in May 2013. No competency evaluation was found for GNA #59. On 9/01/23 at 10:39 AM in an interview with the Human Resources Manager #55, she explained that she did not…

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

Based on review of Geriatric Nursing Assistant (GNA) employee records and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months. This was evident for 3 (GNA # 44, #57, and #59) out of 3 GNAs records reviewed during this survey. The findings include: On 9/06/23 at 11:16 AM in an interview with the Director of Nursing (DON) and the Infection Preventionist Nurse (IP) #3, the surveyor requested employee files for 3 randomly selected facility GNA's. A review of these records revealed that: 1. GNA #44 was hired in March 2020. There were no performance evaluations. 2. GNA #57 was hired in March 2018. There were no performance evaluations. 3. GNA #59 was hired in May 2013. There were no performance evaluations. On 9/06/23 at 1:57 PM in another interview with IP #3, she provided a checklist of training records for the selected staff, but the list did not contain any information regarding performance evaluations. The surveyor again requested IP #3 to submit performance evaluations for the above 3 GNA's. On 9/07/23 at 10:49 AM 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews and observations it was determined the facility staff failed to: 1) maintain complete and accurate medical records in accordance with accepted professional standards, and 2) maintain a psychological consult on the medical record. This was evident in 7 (Resident #78, #91, #126, #128, #133, #153 and #128) of 18 residents reviewed for their care during this survey. The findings include: 1) On 08/29/23 at 9:10 AM, a review of Resident #126's medical record and MD00162951 revealed Resident #126 was transferred to the hospital on 1/1/21 at 6:30 PM due to an acute change in mental status. Resident #126 did not return to the facility. Further review of Resident #26's medical record revealed 6 medications administered on 1/3/21 at 9 AM. On 8/29/23 at 11:45 AM the electronic health records director (staff #6) reviewed Resident #126's closed medical records. She was asked when the resident was discharged from the facility and she stated January 1, 2021. She acknowledged 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 interview and documentation review, it was determined the facility failed to ensure that staff received training regarding abuse, neglect, exploitation, misappropriation of resident property. This was evident for 6 staff of 11 staff (Registered Nurse (RN) #42, Geriatric Nursing Assistant (GNA) #43, GNA #58, GNA #60, Licensed Practical Nurse (LPN) #61, and LPN #62) reviewed for training records. The findings include: On 8/31/23 at 1:30 PM the surveyor requested the training records for 8 randomly selected nursing staff from the Director of Nursing (DON). The review revealed that the following staff had no training record for abuse, neglect, and misappropriation: GNA #58, who was hired on 6/20/23 GNA #43, who was hired on 5/30/23 (had already worked as an agency staff at the facility) RN #42, who was hired on 9/21/22. LPN #61, who was hired 9/22/21. GNA #60, who was hired on 12/13/22. LPN #62, who was hired on 9/08/22. On 9/01/23 at 10:39 AM an interview was conducted with Staff #55, Director of Human Resources. She was asked about required nursing staff training and she…

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

Based on medical record review and interview of facility staff it was determined the facility failed to identify the responsible party of a resident. This was evident for one (Resident #144) out of three residents reviewed for resident rights during the facility's recertification survey. The findings include: On 9/13/23 at 12:27PM, the surveyor reviewed the medical records for Resident #144, who had resided on the Alzheimer's Care Unit (secured unit) and was listed on the medical records as their own responsible party. On 9/14/23 at 11:15AM the surveyor reviewed the paper chart medical record which revealed two medical certifications of incapacity for decision making regarding Resident #144. Subsequently, the surveyor reviewed the advance directives for Resident #144 which specified their chosen appointment of healthcare agent(s). During review of Resident #144's paper chart medical record, the surveyor found the facility's consent to treat form. The consent to treat form dated 7/7/2022, revealed documentation of the consent for treatment of Resident #144 had been obtained per phone…

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 review of pertinent facility policies and documentation, it was determined that the facility failed to: 1.) prevent incidents of abuse related to using a residents image on social media, and 2.) failed to ensure that their residents were free of neglect. This was evident for 2 (Resident #62 and #93) of 19 abuse investigations, including complaints and facility reported incidents. The findings are: 1) A review of facility-reported incident MD00184933 on 9/11/23 revealed that the facility reported a breach in the social media policy involving Resident #93. The facility's investigation initiated on 10/24/22 substantiated that 3 GNA's (GNA #41, #69, #70) were involved in an authorized disclosure of a resident's image onto their personal cell phones and then subsequently onto the social media platform Tik Tok. Additionally, one of the GNA's uploaded the resident's image onto the social media platform with an inappropriate caption attached to it and an inappropriate song playing in the background. The facility's investigation revealed 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 record review and staff interviews, it was determined that the facility failed to protect a resident's right to be free from misappropriation and/or exploitation. This was evident for 1 (#78) of 6 residents reviewed for personal property during an annual survey. The findings include: On 9/14/23 at 3:12 PM review of a facility reported incident MD00195946 revealed that License Practical Nurse (LPN) #25 and charge nurse assigned to Resident #78 on 8/21/23 took Resident #78's Narcotic Oxycodone a control medication used to treat moderate to severe pain, without Resident #78's permission and gave to Resident #3 who ran out of their medication. LPN #25 signed off on the Medication Administration Record (MAR) that the narcotic medication was given to Resident #78 when the medication was given to Resident #3. On 9/15/23 at 3:30 PM in an Interview with LPN #25, she stated that Resident #3 told her that the prior shift did not medicate him/her for pain for over 4 hours because the medication was not available, and they were waiting for pharmacy to deliver the refills. LPN #25 stated…

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

Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#74, #111, #96) of 7 residents reviewed for hospitalization. The findings include: 1) On 8/18/2023 at 9:00 AM, in an interview with Resident #74's family member, s/he stated that the resident fell on Wednesday night in their room and hit his/her forehead. S/he added that the facility staff called her/him, and Resident #74 was sent out 911 to the hospital. When asked if s/he was given a written notification when Resident #74 was sent to the hospital, Resident #74's family member stated that s/he has always been told verbally when the resident was transferred out but not in writing. Review of the medical record for Resident #74 on 8/22/2023 at 12:26 PM revealed that Resident #74 was transferred to an acute care facility on 8/16/2023. However, there was no documentation and/or evidence in the record indicating that the facility 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 observations, record review, and interviews it was determined that the facility failed to develop and implement a comprehensive care plan. This was evident for 3 (#121, #128, and #153) of 6 residents reviewed for care planning 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. 1) In an observation conducted on 8/17/23 09:43 AM Resident #121 was observed walking next to his/her bed, adjusting things on the bedside table. When the surveyor asked the resident how he/she communicated with staff, he/she was only able to say I can't. The resident gave no other verbal responses, but nodded his/her head to yes and no answers. The resident picked up a pad of paper but was unable to write any words, the paper had scribbled shapes on it. On 8/30/23 at 11:56 AM a review of Resident #121's care plan revealed that there was no care plan for communication. On 8/30/23 at 2:12…

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 meet professional standards of practice as evidenced by: 1) failing to ensure nursing staff documented on Medication Administration Record (MAR) and Controlled Drug Administration Record (known as control sheet), 2) taking a narcotic medication from one resident to medicate another. This was evident for 3 (#3, #77, and #148) out of 11 residents reviewed for narcotic medication administration. The findings include: Oxycodone is an opioid pain medication, sometimes called a narcotic. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, it is a standard of nursing practice to administer narcotic medication only from sources that can be accounted for and reconciled. This practice discourages the diversion of abusable medication and ensures that narcotic medication is tracked according to federally mandated standards.…

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 failed to ensure residents' bathing preference for showers. This was evident for 1 (Resident #142) out of 2 residents reviewed for activities of daily living during the facility's recertification survey. The findings include: On 9/07/23 at 12:49PM the surveyor reviewed Resident #142's plan of care which noted the resident was at risk for decline in their ADL (activities of daily living) self-care performance. Further review of the care plan revealed the following goal for the resident: Resident will demonstrate increased independence with ADL completion. On 9/07/23 at 1:48PM, the surveyor requested all shower and bathing documentation for Resident #142 from the facility administrator. Review of the medical record on 9/11/23 at 11:52AM revealed an admission initial evaluation for Resident #142 dated 5/20/22, which specified the resident's preference for bathing was showers during the daytime. Upon review of the facility's bathing documentation for Resident #142, two showers were documented as performed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview of facility staff it was determined the facility failed to: 1) ensure a resident received a timely wound consult, 2) consistently and timely implement recommendations made by the wound care provider, 3) ensure treatment recommendations made by the wound care provider were provided timely for a resident. This was evident for 3 ( #131, #137, and #144) out of 7 residents reviewed for wounds during the facility's recertification survey. The findings include: 1) On 9/14/23 at 12:23PM, the surveyor reviewed the medical record for Resident #144 which revealed a nurse note upon the resident's admission on [DATE] which documented the following information for the resident: Skin intact no open area noted. Review of the medical records by the surveyor for Resident #144 on 9/15/23 at 10:49 AM, revealed a nursing skin grid pressure note created on 8/08/22 at 9:05 PM documenting a new skin pressure area to the resident's right heel. Additionally, an SBAR communication form (a form…

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

Based on observations, record review, and interview of facility staff it was determined the facility failed to implement the resident's care plan for a resident at risk for falls. This was evident for 1 (#91) out of 5 residents reviewed for falls during the facility's recertification survey. The findings include: On 8/16/23 at 12:02PM the surveyor observed Resident #91 in their bed with only one floor mat in place next to their bed. On 9/19/23 at 11:29AM the surveyor observed Resident #91 in their bed with only one floor mat in place next to their bed. Review of the medical record on 9/19/23 at 11:29AM revealed an active order for bilateral (both sides) floor mats while the resident is in bed. On 9/19/23 at 11:56AM, the surveyor continued to observe only one floor mat in place next to the bed of Resident #91. On 9/20/23 at 9:56AM the surveyor observed Resident #91 in their bed with only one floor mat in place next to their bed. On 9/20/23 at 10:34AM the surveyor continued to observe Resident #91 in their bed with only one floor mat in place next to their bed. On 9/20/23 at 10:34AM…

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 physician progress notes were not placed timely in the resident medical records. This was evident for 3 (#13, #93, and #131) of 12 residents reviewed during the annual survey. The findings include: 1) Review of the medical record on 8/28/23 at 10:21AM revealed delays from the time Resident #131 was seen by the physician/nurse practitioner and the time their notes for the visit were uploaded and available on the electronic health record system. a. On 3/31/21, the resident had a physician visit. The physician notes for that visit were not documented as uploaded to the medical record until 5/17/21. b. On 4/04/21, the resident had a physician visit. The physician notes for that visit were not documented as uploaded to the medical record until 5/17/21. c. On 4/07/21, the resident had a nurse practitioner visit. The notes for that visit were not documented as uploaded to the medical record until 5/17/21. d. On 4/11/21, the resident had a physician visit. The physician notes for that visit were not documented as…

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, policies and other pertinent documentation, and interviews it was determined that the facility failed to ensure narcotics removed from the resident's supply were administered to the resident. This was found to be evident for 4 (#19, #29, #78, and #148) out of 11 residents reviewed for narcotic usage during the survey. The findings include: 1) On 9/18/23 at 1:53 PM, review of complaint MD00186849 revealed that Resident #148 resided the facility from 12/14/22 to 12/28/22 for pain management after his/her spinal instrumentation and fusion. Further review of Resident #148's medical record revealed that the resident had an order of Oxycodone Hcl tablet 10mg by mouth every 4 hours as needed, started on 12/14/22. On 9/19/23 at 09:01 AM review of Resident #148's Controlled Drug Administration Record (Control Sheet) was reviewed and revealed the following: One tablet of Oxycodone 10mg. was administrated on 12/15/22 (without time documented.) The previous dose documented at 6 PM, and next dose documented at 10:30 PM. There was no other dose documented on…

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

Based on review of the medical record and interview with staff it was determined the facility staff failed to ensure that the attending physician documented in the medical record that drug irregularities identified by the consultant pharmacist were reviewed. This was evident for 1 (#46) of 2 residents reviewed for Antibiotic Use. The findings include: Resident #46's medical record was reviewed on 9/1/23 at 10:34 AM. Monthly pharmacist review notes indicated that the clinical pharmacist conducted monthly reviews of Resident #46's drug regimen. The review notes for 12/22/22, 2/28/23, 5/30/23, 6/6/23, 7/24/23 indicated No apparent medication irregularities noted at this time. The notes for 9/29/22, 10/27/22, 11/28/22, 2/5/23, 3/30/23, 4/28/23 indicated Irregularities noted and/or recommendation(s) made. Please see Consultant Pharmacist report. Further review of Resident #46's electronic and paper medical record failed to reveal the consultant pharmacists' recommendations/irregularities as indicated with the physician's response. On 9/1/23 at 11:19 AM Registered Nurse/Unit Manager (UM)…

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 the medical record and interview with staff it was determined the facility staff failed to: 1) ensure that the residents drug regimen was free from unnecessary drugs and 2) administer medication in accordance with the standards of practice. This was evident for 1 (#46) of 2 residents reviewed for Antibiotic Use, and 1 of (#34) of 11 Controlled drug administration records reviewed and a review of a self-report during the recertification survey. The findings include: 1) Resident #46's medical record was reviewed on 8/22/23 at 9:12 AM and revealed a change of condition Nursing Progress note dated 5/18/23 22:19 (10:19 PM) Section 8. Skin evaluation indicated that the resident had Redness (Cellulitis). The section titled Appearance indicated Resident started on Augmentin (an antibiotic belonging to the penicillin class of antibiotics) 875mg for cellulitis of the back right hand and to switch to ceftriaxone (a cephalosporin antibiotic) 1g(gram) IV (intravenous) Q (every) daily when midline or PICC line (specialized IV line) is placed. The note indicated that the Primary…

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

Based on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 2 (#92, #62) of 5 residents reviewed for dental services during the survey. The finding include: 1) On 8/16/2023 at 10:36 AM an interview was conducted with Resident #92 who stated that s/he has three (3) broken teeth and had not seen a dentist to take them out. The resident added that s/he had not gone for an outside doctor's appointment for over a year. On 9/13/2023 at 11:18 AM, in an interview with the Unit Manager (UM #16), she stated that Resident #92 was being seen in the facility by the Health Drive Dental Group and Oral hygienist. She stated that Resident #92 had not gone out for any appointment because the resident has been refusing to go on a wheelchair and the offices cannot accommodate a stretcher. On 9/14/2023 at 10:36 AM, in an interview with the Director of Social Services (Staff #2), she stated that she 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 interview and record review, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident for 1 (Resident #159) out of 3 residents' antibiotic use reviewed during the recertification survey. The findings include: On 8/17/23 at 2:15 PM, a portion of the investigation for facility reported incident MD00194564 and complaint MD00194510 revealed that Resident #159 had resided in this facility for several years with diagnoses of dementia, schizophrenia, bipolar, and morbid obesity. On 7/14/23, the resident was transferred to the hospital for an altered level of consciousness evaluation. Further review of the resident's medical record revealed that the resident was seen by his/her physician (Staff #33) on 7/04/23 for confusion evaluation. Staff #33 ordered blood work and Augmentin (antibiotic medication) 875-125mg for five days for bacterial infection, start date 7/05/23 at 0900. One of the on-call physicians (Staff #71) prescribed sulfamethoxazole-trimethoprim tablet 800-160mg twice a day for seven days for a Urinary Tract…

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.