Rosewood Rehab And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #216's face sheet showed he/she had been admitted to the facility on [DATE] with the following diagnoses: -Suicide attempt (an act in which a person tries to kill themselves but survives). -Alcohol abuse (a pattern of drinking that interferes with day to day activities). -Depression. -Adjustment disorder (a mental and behavioral condition that exhibits an extreme reaction to stress). Review of the resident's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact. -He/She took scheduled and as needed pain medications. Review of the resident's POS, dated May 2025, showed: -The resident did not have an order to self administer medications. -Norco Oral Tablet (a strong pain medication with the risk for addiction with Tylenol- an over the counter pain medication) 5/325 milligrams (mg), give one tablet by mouth every four hours as needed for pain. Not to exceed three grams (of Tylenol) per 24 hours. -Tylenol Oral Tablet 325 mg give two tablets by mouth every six hours as needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident # 216) had a follow up dental appointment to have multiple teeth removed, out of 35 sampled residents. The facility census was 259. Review of the facility's policy, Dental Services, dated October 24, 2022, showed: -All residents would receive appropriate oral care including denture care. -Assessment of the oral cavity and teeth was performed upon admission and as necessary. -The facility would assist residents with referrals for dental services. -The facility would refer and or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the resident. -Emergency dental services include but were not limited to; -Acute pain in teeth, gums, or palate. -Broken or damaged teeth. 1. Review of Resident # 216's face sheet showed: -He/she was admitted to the facility on [DATE]. -He/she needed for assistance with personal cares. -Diagnosis of…

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

Based on observation, interview, and record review, the facility failed to ensure the dignity of one sampled resident (Resident #1) when on 11/29/24 at 5:37 A.M., Certified Nurses Aide (CNA) A argued and cursed at the resident out of three sampled residents The facility census was 258 residents. The Administrator was notified on 12/2/24 of Past Non-Compliance which occurred on 11/29/24. The facility had provided education to all staff prior to their next shift on customer service, abuse and neglect. The deficiency was corrected on 11/30/24. Review of the facility's policy titled Privacy and Dignity dated 10/24/22 showed: -The facility promoted resident care in a manner and an environment that maintained or enhanced dignity and respect, in full recognition of each resident's individuality. -Staff were to treat the residents with respect including respecting their social status, speaking respectfully, and listening carefully. 1. Review of Resident #1's admission Record showed he/she admitted to the facility with a diagnosis of Amyotrophic Lateral Sclerosis (ALS- a nervous system…

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, the facility failed to implement and maintain an effective infection control and prevention program when staff failed to follow the facility's infection control policies and guidance by the Centers for Disease Control (CDC) related to Coronavirus Disease 2019 (Covid-19 - an infectious disease caused by severe acute respiratory syndrome) when staff failed to complete follow-up Covid-19 tests for two residents (Resident #2 and Resident #4) who had shared rooms with residents who became positive for Covid-19 and when staff failed to follow infection control practices related to hand washing and personal protective equipment (PPE - items such as masks, gowns,and gloves) usage when working in areas/rooms with Covid-19 positive residents. The facility census was 260. Review of the CDC's website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 05/08/23, showed the following: -Asymptomatic patients with close contact with someone…

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, interview, and record review, the facility to provide a safe, functional, sanitary, and comfortable environment for all residents, staff, and public when staff failed to maintain two beds and failed to keep flooring cleanable and sanitary. The facility census was 260. Review of the facility's policy titled Maintenance Services, revised 10/24/22, showed the following: -Purpose of the policy was to protect the health and safety of residents, visitors, and facility staff; -The Maintenance Department maintained all areas of the building, grounds,and equipment; -The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of the maintenance department may include, but are not limited to, maintaining a building free from hazards, establishing priorities in providing repair service, maintaining all mechanical, electrical, and patient care equipment in safe operating condition, providing routinely scheduled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure there were enough staff present to meet the care needs for one sampled resident (Resident #1) out of 10 sampled residents, when on [DATE] Resident #1 had not been checked on for approximately seven hours due to the lack of enough staff on 3 North, was found in his/her room with a large amount of blood and feces smeared all over the room, the indwelling catheter on the floor with the bulb inflated, and the resident was deceased with rigor mortis present. The facility census was 275 residents. Review of the Facility Assessment, dated 12/2023, showed: -The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. -Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. -Using a competency-based approach focuses on ensuring that each resident is…

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, interview, and record review, the facility failed to ensure the resident's environment was clean, safe, and comfortable when on 6/13/24 odors, stains, and debris were noted in the common carpeted areas on the second floor, third floor, and fourth floor and failed to keep the trim in good repair in resident common areas, and one resident's room maintained for cleanliness and sanitation. The facility census was 260 residents. A policy was requested regarding cleaning the carpets and flooring but not provided. 1. Observation on 6/13/24 at 8:40 A.M., showed an musty odor in the air as exiting off the elevator on the second floor. Observation on 6/13/24 at 9:35 A.M., showed the carpeted floors on the fourth floor south had debris scattered over the carpet. Observation on 6/13/24 at 9:42 A.M., showed the carpet in the alcove on the fourth floor north had debris scattered throughout the alcove. Observation on 6/13/24 at 10:02 A.M., showed a large stain on the carpet between rooms [ROOM NUMBERS].…

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, the facility failed to keep the Dry Storage (DS) room, walk-in refrigerator, and walk-in freezer floors clean; to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to consistently measure and document hot food temperatures at the ovens and/or stoves to ensure they were suitably cooked, and cooked longer if needed, to lessen the chance of bacterial contamination; to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and to separate damaged foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 250 residents with a licensed capacity for 300 residents at the time of the survey. 1. Review of the meal times provided by the Dietary Manager (DM) on 8/16/23 at 9:06 A.M. showed that breakfast was served…

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, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility failed to ensure staff was following infection control guidelines during medication pass by not cleaning the hub on the insulin pen and not cleansing hands after glove changes for four sampled residents (Resident #130, #188, #146, and #111) out of 35 sampled residents. The facility census was 250 residents with a licensed capacity for 300 residents at…

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

Based on interview and record review, the facility failed to ensure resident funds were placed in an account separate from the facility operating account. The facility failed to provide residents refunds of their personal funds from the operating account in a timely manner for eight supplemental residents (Resident #656, #657, #658, #659, #660, #661, #662, #663). The total amount of personal funds withheld and not returned to the resident or responsible parties was $17,450.34. The facility census was 250 residents at the time of survey. 1. Review of the facility's maintained Accounts Receivable (A/R) Aging report for the period 1/2023 to 8/21/2023, showed personal funds still being held in the facility's operating account for the following residents: -Resident #656 had $125.00 held in the facility operating account. -Resident #657 had $791.00 held in the facility operating account. -Resident #658 had $2779.96 held in the facility operating account. -Resident #659 had $170.10 held in the facility operating account. -Resident #660 had $3165.57 held in the facility operating account.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document participation of the resident and/or the resident's representative(S) regarding care plan development for one sampled resident (Resident #201): to ensure three sampled residents (Resident #247, #18 and #230) were invited to his/her care plan meeting; and to invite the resident's responsible party to care plan meetings for one sampled resident (Resident #37) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's Care Planning Policy, dated 10/24/22, showed: -The purpose of the policy was to ensure a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. -The Care Plan served as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's attending physician, and the Interdisciplinary Team (IDT) worked to help the resident move toward resident-specific goals that addressed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Activities of Daily Living (ADL), bathing/showering, for four sampled residents (Resident #27, #47, #93 and #138,) out of 35 sampled residents by not providing scheduled baths or showers, causing poor hygiene. The facility census was 250 residents. Review of the facility's Showering a Resident policy, dated 10/24/22, showed: -A bath/shower was given to the residents to provide cleanliness, comfort and to prevent body odor. -Residents were offered a shower a minimum of once weekly and given per resident request. -Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse. -Update the resident's care plan as needed. -Note: No procedure for documentation of bathing/showering and/or resident refusal was noted. Review of the bath sheet binder behind the third floor south nurse station showed: -Bath/shower sheets were noted for some residents. -Bath/shower sheets were not consistently 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of meaningful activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for eight sampled residents (Residents #37, #39, #75, #98, #151, #232, #233 and #505) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's Activities Program policy dated as revised 10/24/22 showed: -The facility was to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent and to enable the resident to maintain the highest attainable social, physical and emotional…

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, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered, if applicable, by the State in which practicing and was eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or had two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program; or was a qualified occupational therapist or occupational therapy assistant; or had completed a training course approved by the State. The facility census was 250 residents. Review of the facility's Activities Director Job Description dated 6/1/05 showed: -The Activity Director was responsible for the coordination, development, maintenance of a quality activity program by utilizing staff expertise, family and community resources in accordance with the comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two sampled residents (Resident #140 and #241) or the resident's family members were offered the right to formulate and/or obtain existing advanced directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) out of 35 sampled residents. The facility census was 250 residents. Review of the facility Advanced Directives policy dated 10/24/22 showed: -If a resident did not have an Advanced Directive, the Facility would provide the resident and/or resident's next of kin with information about advanced directives upon request. -An Advanced Directive was defined as a resident's written preference regarding treatment options. -Upon admission, the Admissions Staff or designee would provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft by not completing grievance investigations timely for two sampled residents (Resident #9 and #102) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's Grievances and Complaints Policy, dated 10/24/22, showed: -Any resident was able to file a grievance or complaint concerning theft of property. -Any alleged misappropriation of property was to be reported to the administrator immediately (not more than 24 hours after the alleged incident). -The facility identified a Grievance Official who was responsible for: --Oversight of grievance process. --Tracking grievances through to their conclusion. --Led any necessary investigations by the facility. --Issued written grievance decisions to the resident. -The department director of an involved employee was notified of the nature of the complaint and that an investigation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) for three sampled residents (Residents #84, #247 and #39) out of 35 sampled residents. The facility census was 250 residents. Review of the facility's PASRR Policy, dated 10/24/22, showed: -The purpose of the policy was to achieve placement of individuals in the least restrictive environment possible and be able to receive all services required by their physician and mental condition. -The facility ensured all Level I PASRR's were completed by the transferring facility, upon admission, or as soon as possible, by the facility for all applicants. -Nursing staff completed PASRR screenings for residents admitted to the facility without a screening. 1. Review of Resident #84's quarterly Minimum Data Set (MDS- a 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 interview and record review, the facility failed to provide one sampled resident (Resident #247) with a summary of his/her baseline care plan and to include the resident's diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of 35 sampled residents. The facility census was 250 residents. Review of the facility Care Planning policy dated 4/24/22 showed: -The facility would develop a person-centered baseline care plan for each resident within 48 hours of admission. -The baseline care plan would include the initial goals of the resident. -The baseline care plan summary must be provided to the resident and/or the resident's representative by the time the comprehensive care plan was completed. -Resident medical records must contain evidence that the baseline care plan summary was given to the…

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

Based on interview and record review, the facility failed to have parameters listed in the medication orders for Acetaminophen containing medications for one sampled resident (Resident #5) of out of 35 sampled residents. The facility census was 250 residents. Review of the facility policy titled Medication-Administration revised October 24, 2022 showed: -The licensed nurse would know the following information about any medication he/she would have administered any precautions or special considerations. -The residents Medication Administration Record (MAR) would be reviewed for special considerations for administration including acceptable professional standards and principles. 1. Review of Resident #5's Medication Review Report dated 8/21/23 showed the following orders: -Hydrocodone-Acetaminophen (narcotic pain medication with Acetaminophen compounded in it) 5 milligrams (mg.) of Hydrocodone with 325 mg of Acetaminophen compounded together. Give one tablet by mouth every six hours as needed for pain. -Hydrocodone-Acetaminophen 5 mg of Hydrocodone with 325 mg of Acetaminophen…

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, the facility failed to ensure the correct setting for a Low Air Loss mattress (LAL - a mattress that provides airflow to help keep skin dry as well as to relieve pressure with alternating air cells that expand and contract to shift pressure) for one sampled resident (Residents #190) with a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; dead tissue may be present on some parts of the wound bed; it often includes undermining -the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface and tunneling - a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) out of 35 sampled residents. The facility census was 250 residents. Review of the facility Physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure hydration opportunities and assistance was provided to three sampled residents (Residents #75, #98, and #232) who were dependent upon staff for their hydration needs out of 35 sampled residents. The facility census was 250 residents. Review of the facilities Nutrition/Hydration Management policy and procedure, revised 10/24/22, showed nutrition management included: -Maintaining acceptable parameters of nutritional status. -Developing, implementing and on-going assessment of the nutrition/hydration program through the Interdisciplinary process. Review of the facility census, dated 8/16/23 showed 48 residents were living on the 2 South secured unit. 1. Review of Resident #75's admission Record showed he/she was originally admitted with the following diagnoses: -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language,…

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, the facility failed to ensure staff clarified orders with the physician for use of either Bi-level Positive Airway Pressure (BiPAP a machine set to use two levels of mild air pressure, one for inhalations and one for exhalations, delivered by mask to keep breathing airways open during sleep) or Continuous Positive Airway Pressure (CPAP the same as the BiPAP machine with settings to deliver continuous mild air pressure rather than bi-level pressure to keep breathing airways open during sleep) and for oxygen concentrator use; to obtain orders and instructions for the cleaning and storage of these devices and related supplies, and to assess and document the use of the BiPAP/CPAP and oxygen concentrator, ensure the cleansing and sanitary storage of the resident's BiPAP/CPAP nasal mask and tubing, and ensure the resident's oxygen concentrator tubing was dated and properly stored when not in use for one sampled resident (Resident #230) out of 35 sampled residents. The facility census was 250 residents. The facility's Respiratory Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dental services were provided to address loose teeth in a timely manner for one sampled resident (Resident #140) out of 35 sampled residents. The facility census was 225 residents. Review of the facility Dental Services policy dated 10/24/23 showed: -Instruction to refer and/or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointments for the resident, if needed or requested and arranging transportation to and from the dentist's office. 1. Review of Resident #140's physician's order dated 10/27/22 showed an order for a regular diet, regular texture, regular consistency. Review of the resident's physician's order dated 4/3/23 showed dental consult related to a loose tooth. Review of the resident's progress notes, assessments and miscellaneous sections in his/her electronic health record (EHR) dated 4/3/23 to 8/22/23 showed: -No information regarding 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 interview and review of facility documentation, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed to drive quality assurance (QA) measures that addressed resident care and safety. This failure had the potential to affect all 250 residents who currently live in the facility. 1. Record review of the facility policy, revised 01/2008, showed: -The quality improvement committee was appointed to provide oversight for the quality assurance program. -The functions of the quality improvement committee: --Determine quality improvement programs. -Assess effectiveness of staff in designing, measuring, assessing, and improving the resident care and organizational functions by: ---Reviewing the clinical outcome benchmark data. ---Reviewing data relevant to the needs and expectations of our customers. ---Reviewing customer complaints. ---Reviewing reports from the departments and process improvement teams. --Act on reports from the quality improvement team. --Facilitate communications of team progress and improvements through the levels of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 250 with a licensed capacity for 300. 1. Record review of the facility's disaster manual entitled The Rosewood Emergency Plan, last reviewed and updated on 1/15/21 and obtained from the 2nd floor's South Nurse Station, showed a 3-page document under the tab Water Program that did not include the following CMS requirements for a waterborne pathogen program: -A facility-specific risk assessment that considers the…

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

Based on observation, interview, and record review, the facility failed to repair or replace three kitchen appliances to maintain safe operating condition according to manufacturers' specifications for the preparation of meals for the residents. This deficient practice had the potential to affect all residents who ate food from the kitchen. The facility's census was 250 residents with a licensed capacity for 300 residents. 1. Observations during the initial kitchen inspection on 12/6/21 at 9:40 A.M., showed the facility's electric convection oven, an electric combi oven (a combi has a combination mode which uses both dry heat and steam to maintain exact humidity levels, thus providing more control of the moisture levels in food), and an electric pass-thru refrigerator were not in proper working order. During an interview on 12/07/21 at 2:31 P.M., the Dietary Manager (DM) said the following: -The top combi oven and the lower convection oven were out of service, but he/she thought the facility may have gotten bids for their replacement. -The pass-through refrigerator was also 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 interview and record review, the facility failed to ensure the physician and family were notified of possible sexual abuse for two sampled residents (Resident #126 and #205); for one closed record resident (Resident #290) and for sexually inappropriate behaviors for one sampled resident (Resident #222) out of 37 sampled residents and six closed sample residents. The facility census was 250 residents. Record review of the facility's Abuse Prevention Program policy, dated 3/18, showed: -Any allegation of abuse will be reported immediately to the facility Administrator or his/her designee, who will follow Federal requirements for reporting to the state licensing agency, law enforcement, resident's representative and resident's primary physician. Record review of the facility's Physician Communication policy, dated 5/09 and reviewed 2/13, showed: -There was a higher level of acuity and urgent interactions with clinical staff and physicians in regard to long-term care residents versus the general population.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report sexual abuse to the State Agency (SA) or local law enforcement when one resident (Resident #126) who was assessed to have impaired cognitive function related to Alzheimer's and dementia, was twice found unclothed, in a bed with a resident assessed as cognitively intact (Resident #205). Resident #205 was also unclothed, and once was found on top of Resident #126. The facility also failed to report abuse when Resident #290, a resident with a diagnosis of dementia with behavioral disturbances, was found on top of an unknown resident in bed. Additionally, the facility failed to report when Resident #289, who had a diagnosis of dementia with behavioral disturbances, a history of aggressive sexual advances towards others residents (including Resident #203) by touching them, kissing them, and making graphic sexual comments to them. Lastly, the facility failed to report when an unidentified resident was sexually abused by Resident #222, who had severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedures to ensure a thorough investigation of resident to resident sexual contact was completed to determine whether sexual abuse occurred. This deficient practice affected one resident (Resident #126) who was assessed to have impaired cognitive function related to Alzheimer's and dementia, was twice found unclothed, in a bed with a resident assessed as cognitively intact (Resident #205). Resident #205 was also unclothed, and once was found on top of Resident #126. The facility also failed to thoroughly investigate when Resident #290, a resident with a diagnosis of dementia with behavioral disturbances, was found on top of an unknown resident in bed. Additionally, the facility failed to thoroughly investigate when Resident #289, who had a diagnosis of dementia with behavioral disturbances, a history of aggressive sexual advances towards others residents (including Resident #203) by touching them, kissing them, and making…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff maintained current cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure consisting of chest compressions, often combined with artificial breathing, to manually preserve intact brain function, circulation and breathing to an unresponsive person) certification, failed to know if CPR certified staff were available each shift who could provide CPR to residents who needed it, and failed to monitor which staff had maintained CPR certification. The facility census was 250 residents. Record review of the facility's Cardiopulmonary Resuscitation/Emergency Response Policy dated 4/2012 and revised 6/2016 showed: -Nursing staff would be provided guidelines for providing prompt and appropriate emergency interventions to persons at the facility with full code, (all resuscitation procedures would be provided to keep the person alive), status throughout ongoing training, validation of competency, and performance roles. -Registered Nurses…

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, interview, and record review, the facility failed to provide meaningful activities to meet the interests of and support the physical, mental, and psychosocial well-being of five sampled residents residing on the 200 North Secure Care Unit (SCU)(Residents #42, #71, #90, #188, and #207) out of 37 sampled residents; and failed to provide activities for residents residing on the 200 North SCU. The facility census was 250 residents. There was no record of activities scheduled or posted for the 200 North SCU. Record review of the facility's Activity Program Policy, original date of August 1998 and most recently reviewed in May 2016, showed: -The Activity Program was designed to provide therapeutic benefit and maintenance of normal activity which support the individual resident's needs. -Activities were scheduled daily and residents were given an opportunity to contribute to the planning, preparation, conducting, clean-up and critique of the program. -The Activity Program consists of individual,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a coordination of care between Hospice (end of life) and the facility and failed to ensure staff were instructed where and how to retrieve the Hospice providers electronic documentation for eight sampled residents (Residents #10, #71, #73, #125, #146, #176, #209, and #211) out of 37 sampled residents. The facility census was 250 residents. Record review of the facility's Hospice Care policy, revised on 10/15, showed: -Hospice services are provided to augment the services provided by the facility. The facility retained protective oversight of the resident and continued to provide services for the resident as before the Hospice admission. -Hospice services provided a comprehensive, individualized care plan based on the current needs of the residents and will be placed in the clinical record once admitted . The plan of care was updated as the resident's condition dictated. -It was the responsibility of the Hospice service to communicate this plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent accident hazards by not keeping two medication carts locked when unattended and failed to ensure fall interventions were put into place for one sampled resident (Resident #146) out of 37 sampled residents. The facility census was 250 residents. A policy for medication carts was requested and was not received at time of exit. 1. During an observation on 12/8/21 at 3:52 P.M., on the Three North unit showed: -A medication cart unlocked in the common area near the Nurses Station. -Two nurses and two Certified Nursing Assistants (CNA) at the Nurses Station. -Two residents in wheelchairs who could maneuver themselves in the common area near the unlocked medication cart. -One resident in a chair who moved him/herself from the wheelchair to the chair in the common area near the unlocked medication cart. Observation on 12/8/21 at 4:15 P.M. on the Three North unit, showed: -The medication cart still unlocked. -A nurse took an item out of…

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

Based on observation, interview, and record review, the facility failed to post complete staffing information to include the the facility census and the actual hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), and Certified Medication Technicians (CMTs) directly responsible for resident care for each shift, in locations throughout the facility that are easily accessible to residents and visitors. The facility census was 250 residents. 1. Record review and observation of staff sheets, dated 12/10/21, 12/11/21, 12/12/21, and one undated showed: -The staffing sheet was posted at the receptionist's desk, under a glass countertop, on the first floor at the entry of the facility. -A copy of this staffing sheet was not posted in a prominent place accessible to residents on the second, third, or fourth floors where residents resided. Observation on 12/10/21 at 10:26 A.M., of unit 3-South showed: -Staffing and assignment sheets for the unit were posted on the wall behind the nurses' station. -These sheets did not include the…

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

Based on observation, interview, and record review, the facility failed to keep the kitchen, dry storage, walk-in refrigerator and walk-in freezer floors clean; failed to retain thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; failed to change the deep fryer oil in a timely manner; failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to separate damaged food; and failed to ensure the proper refrigeration of food. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 250 residents with a licensed capacity for 300. 1. Observations during the Kitchen inspection on 12/7/21 between 10:10 A.M. and 11:26 A.M., showed the following: -There were crumbs and paper debris under the racks in walk-in freezer #1. -There were crumbs, a plastic cup, and paper debris under the racks in walk-in freezer #2. -There were crumbs, food debris, pieces of foil, and a 16 ounce (oz.) plastic lidded…

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, the facility failed to update written contracts for the use of outside resources and/or sign and date contracts after a change of ownership occurred. The facility census was 250 residents. A policy was requested related to use of outside resources and the facility did not have a policy related to this. 1. Review showed the facility had a change of ownership on 10/19/2021. Record review of the facility's Medical Director Agreement showed: -An outlined agreement of the Medical Director to provide services to the facility. -The document was signed by the Medical Director on 4/15/10. Record review of the facility's Services Agreement for psychiatric services showed: -An outlined agreement to provide psychiatric services dated 10/11/19. -The contract was signed by the former facility Administrator on 10/14/19. -The contract was signed by the authorized representative of the psychiatric group on 10/15/19. Record review of the Consulting Services Agreement for dining services showed: -An outlined agreement for dietician services. -The contract 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, the facility failed to update an existing hospital transfer agreement after a change of ownership and to put forth a good faith effort to obtain other hospital transfer agreements for hospitals used by the facility. The facility census was 250 residents. A policy was requested related to transfer agreements and the facility did not have a policy related to this. 1. Review showed the facility had a change of ownership on 10/19/2021. Record review of the Facility Transfer Agreement, dated 8/20/18, showed: -A written transfer agreement signed by the former Administrator and the CEO of the hospital. -The transfer agreement outlined transfer of patients, responsibilities of the transferring facility and receiving facility, and billing. During an interview on 12/14/21 at 9:57 A.M., the DON and Administrator said: -There were no other transfer agreements to area hospitals. -The transfer agreement had not been updated after the change of ownership. -The facility utilized multiple other hospitals to transfer residents when hospital services were needed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the significant change in physical or mental condition timely after hospice admission for one sampled resident's (Resident #146) out of 37 sampled residents. The facility census was 250 residents. Record review of the facility's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Completion and Submission Timeframes, dated 2/2015, showed: -MDS assessments are conducted and submitted in accordance with current Federal and State submission timeframes. -The MDS Coordinator or designee is responsible for ensuring that the resident assessments were submitted to the Centers for Medicare and Medicaid (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with Federal and State guidelines. -Significant Change in Status Assessments are required to be completed with an Assessment Reference Date (ARD) of 14 calendar days after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete a Significant Change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) for two sampled resident (Residents #73 and #71) out of 37 sampled residents. The facility census was 250 residents. Requested policy on MDS accuracy and no policy received from facility. 1. Record review of Resident #73's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified Atrial Fibrillation (abnormal heart rhythm). -Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications. -Hyperlipidemia (high levels of lipids in the blood), unspecified. -Hypertension (high blood pressure). -Unspecified Dysplasia (presence of abnormal cells within a tissue or organ) of Prostate. -Major…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to update and revise care plans to reflect residents' current condition and needs for two sampled residents (Residents #71 and #290) out of 37 sampled residents. The facility census was 250 residents. Record review of the facility's Care Plans-Comprehensive policy, updated 7/18, showed: -Care plans were revised as information about the resident's condition change. -Changes in the resident's current condition must be reported to the Minimum Data Set (MDS) coordinator or Assistant Director of Nursing (ADON) so a review of the resident's assessment and care plan can be made. 1. Record review of the Resident #71's face sheet, printed on 12/14/21 showed the resident was admitted to the facility on [DATE] and had the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory,…

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, interview, and record review, the facility failed to ensure dependent residents had baths or showers according to the resident's bath schedule and as needed for three sampled residents (Residents #80, #102, and 165) out of 37 sampled residents. The facility census was 250 residents. 1. Record review of Resident #80's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke affecting the right dominant side. -Acquired absence of Left leg above the knee. -End stage renal disease (ESRD- the kidneys have stopped working). -Dependence on renal dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). Record review of the resident's Care Plan, dated 9/18/21, showed he/she needs: -Assistance with all his/her Activity of Daily Living (ADL- dressing, grooming,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate communication was maintained between the dialysis center and the facility for one sampled resident (Resident #80) out of 37 sampled residents. The facility census was 250 residents. A policy for dialysis communication was requested and not received at the time of exit. Record review of the undated facility and the dialysis center communication form showed the following areas to be filled out by the facility and the dialysis center: -The facility fills out the top half of the form with: --The resident's name and caregiver; --Primary care physician's name; --Date and time of arrival; --From what facility and the phone and fax numbers; --The resident's VS (vital signs- Blood Pressure, Pulse, Respirations, Temperature) and date and time taken; --Time of last meal, if resident needs a meal or snack, and type of diet he/she is on; --If the resident was on a fluid restriction and the amount; --Any significant alerts; --The facility nurse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide medical-related social services for one sampled resident (Resident #126), who was severely cognitively impaired, out of 37 sampled residents. The facility census was 250 residents. The facility did not have a policy for Social Services. 1. Record review of Resident #126's face sheet showed: - The resident's diagnoses were: -Alzheimer's Disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, 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.