Livingston Health & Rehabilitation Center

Based on observation and interview, the facility failed to maintain a clean and safe environment for the living area for 1 (#27) of 24 sampled residents. This deficient practice left the resident feeling frustrated and unable to independently move his bedside table in his room. Findings include: During an observation and interview on 6/2/25 at 2:41 p.m., resident #27 was seated in his wheelchair in the middle of the room. Under resident #27's wheelchair and rest of the floor there were multiple areas with liquid spills with dried dirt adhered to the spills. Resident #27's bed was parallel to the window with dirt all over the floor and under his bed. On resident #27's heat register, there was accumulated dust and dirt. Lying on the floor, next to the heat register, were two green caps/tops from treatment syringes. Under resident #27's bed was a wrapped piece of candy. Next to resident #27's wall, to the right of the dresser, was a pile of dust bunnies entangled with cables/cords. Resident #27 stated housekeeping was in his room every couple of days. During an observation 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 observation, interview, and record review, the facility failed to ensure physician orders were completed, current, and followed by nursing staff, for 2 (#s 43 and 199) of 24 sampled residents. This had the potential to negatively impact a resident's wound healing. Findings include: 1. Review of resident #43's physician order showed there was no order from 5/6/25 to 5/15/25 for his left heel deep tissue injury related to pressure. During an observation and interview on 6/4/25 at 9:56 a.m., staff member M stated they were unable to find a physician order for resident #43 from 5/6/25 to 5/15/25, and they were unsure why there was no physician order during that timeframe. Review of resident #43's physician progress note, dated 5/6/25, showed: .PLAN: Wound # 1 LEFT heel Pressure Treatment Recommendations: 1. Apply Betadine to base of the wound 2. Secure with Silicone bordered foam or other heel protector 3. Change and PRN, 3 times per week, Offloading heel cushion. Wound # 3 LEFT glut Pressure Treatment Recommendations: 1. Apply Zinc Oxide Paste to base of the wound 2. Change…

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

Based on interview and record review, the facility failed to ensure immunizations were reviewed and administered for 1 (#100) of 24 sampled residents, increasing the risk of infections of the residents at the facility. Findings include: During an interview on 6/5/25 at 10:00 a.m., staff member B stated an audit was completed on 6/4/25, and it was found that a consent was needed for resident #100, along with six other residents. Review of resident #100's electronic health record and State of Montana Official Immunization Record showed resident #100 had no pneumonia vaccines administered or declined. Review of a facility policy, titled Influenza and Pneumococcal Vaccine Administration, updated 2/2025 showed: Pneumococcal vaccination occurs with Center residents only, upon admission (after review) and with repeated vaccination occurring per CDC guidelines .

Based on observation and interview, the facility failed to provide a safe shower environment for 1 (#7) of 24 sampled residents. This failure resulted in a resident feeling unsafe while showering in the shower room. Findings include: During an interview on 6/2/25 at 3:03 p.m., resident #7 stated she was independent to shower in the shower room. Resident #7 stated she felt unsafe in the shower room because there was a tiled wall that was slippery when wet and was too thick to grab on to. Resident #7 stated she worried that if she fell, she would not be able to reach the emergency pull string station. She stated the emergency pull string station was located far away from where she sat in the shower chair as it was located on the other side of the half tiled wall. Resident #7 stated, I would hate to see anyone fall. Resident #7 stated she had brought this concern to management before, but stated she felt there was no resolution. During an interview and observation on 6/3/25 at 12:20 p.m., staff member J stated the pull cord station in the shower room on the A hall did look unsafe as it…

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 sufficient nursing staff were available for the provision of resident care and that a licensed nurse was always available. This deficient practice had the potential to affect all residents residing in the facility. Findings include: Review of the facility staffing schedule, dated 12/25/26 showed the facility was staffed with one licensed nurse, and two certified nurse assistants, during the night shift. During an interview on 12/30/24 at 3:44 p.m., staff member A said on 12/25/24, the facility was staffed with one agency LPN, one agency CNA, and one facility CNA during the night. Staff member A said the LPN and agency CNAleft the facility together. Staff member A said with the two of them leaving, the facility was left with no licensed nurse coverage, and only one CNA to care for the 44 residents. Staff member A said she did not know how long the facility was without a licensed nurse. Staff member A said she was not aware of any residents who may have missed medications, and said the nurse documented a refusal 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 sufficiently staff the dietary department with the necessary staff to carry out the normal functions of the department. This deficient practice caused meals to be served late and the department was not meeting resident preferences. Findings include: During an interview on 12/30/24 at 9:55 a.m., during the initial kitchen tour, staff member B said the kitchen was short staffed. Staff member B said he was not aware there were expired nutritional drinks in the reach in refrigerators. He also said the staffing shortage affected the cleanliness of the kitchen. Based on a typed form provided to the surveyor, mealtimes were to be 7:30 a.m. for breakfast, 11:30 a.m. for the noon meal, and 5:30 p.m. for the evening meal. Review of resident council meeting minutes, dated 12/5/24, showed the facility was changing meal times. The new times were explained by the dietary department, and the residents understood the change. During an observation on 12/30/24 at 12:01 p.m., there were three non-dietary staff members serving…

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

Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen, and the dietary storage areas; failed to ensure kitchen staff labeled and dated food in the coolers; and, failed to maintain a clean (dietary/kitchen) environment. This deficient practice increased the risk for the development of foodborne illnesses and deficient practices related to sanitary conditions, for all residents who received food from the kitchen. Findings include: During the initial tour of the kitchen, on 12/30/24 at 9:55 a.m., the following observations were made: - The hot chocolate machine nozzles were soiled. - The juice machine nozzles, and the plates above the nozzles, were heavily soiled with orange and red colored sticky substances. - Small bowls were store in an upright position exposing the eating surface. - The handles on the three reach-in coolers were heavily soiled and sticky. - There were six covered souffle cups labeled OV and not dated. The contents appeared oily. - There were nine souffle cups with a white…

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 report an allegation of resident neglect within 24 hours of the incident, and the designated licensed nurse left the facility during his shift when he was the only nurse on duty at the time, leaving all 44 residents at risk for adverse events. This deficient practice increased the risk of harm or a negative outcome for any resident at the facility, due to the lack of a nursing availability. Findings include: Review of the facility staffing schedule, dated 12/25/26, showed the facility was scheduled to be staffed with one licensed nurse and two certified nurse assistants during the night shift. During an interview on 12/30/24 at 3:44 p.m., staff member A stated on 12/25/24 the facility was staffed with one agency LPN, one agency CNA, and one facility CNA during the night. Staff member A said the LPN, and the agency CNA, left the facility together. Staff member A said with those two staff gone, the facility would have been left with no licensed nurse coverage and only one CNA to care for the 44 residents. Staff member A said…

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 complete a thorough investigation regarding resident-to-resident abuse, including addressing or identifying interventions to stop further abuse, for 4 (#s 3, 21, 71 and 83) of 11 sampled residents. Findings include: 1. A review of a facility reported incident, dated 12/24/24, showed resident #3 and #83 had an allegation of resident-to-resident verbal and physical abuse. Resident #83 yelled and hit resident #3. Both residents were separated and monitored for side effects. The physician and responsible parties were notified. A review of the facility reported incident findings showed resident #83 was counseled that hitting was not appropriate and residents the were separated. The staff were instructed to keep these specific two residents at different tables while dining. During an observation on 12/30/24 during the noon meal, resident #3 and #83 were at the same dining table, sitting next to each other. During an interview on 12/30/24 at 12:20 p.m., staff member K was not aware of any recent resident to resident…

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

Based on interview and record review, the facility failed to update resident care plans in a timely manner for 3 (#s 3, 71, and 83) of 11 residents sampled for physical altercations, weight loss, and pain management. Findings include: 1. A review of a facility reported incident, dated 12/24/24, showed resident #3 and #83 had resident to resident altercation resulting in verbal and physical abuse. Resident #83 yelled and hit resident #3. The initial plan was to separate the residents and both residents would be monitored for side effects. A review of the resident #83's nurse's note, dated 12/26/24, showed resident #83 was fixated on the altercation with resident #3. The note shows the #83 and #3 would remain separated in the dining room, and #83 had a recent failed gradual dose reduction attempt for the antipsychotic medication, Olanzapine. Resident #83's care plan was the original base line care plan which was initiated on 8/23/24, the day after his admission. The care plan was incomplete and not individualized. No additions or updates were made to this baseline care plan. The 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.

Based on interview and record review, the facility failed to ensure a resident was prepared and oriented for discharge home, for 1 (#47) of 1 sampled resident. Findings Include: During an interview on 12/30/24 at 4:49 p.m., staff member G said she would expect discharge planning to be completed prior to the day, or even the day before, a discharge. Staff member G said she had seen the discharge note asking about home health for #47 at the time of discharge, but not prior to discharge. Staff member G was unaware if a referral to a home health agency had been completed. Staff member G said the social service staff person would usually be responsible for discharge planning, but the staff member was out of the facility at the time of #47's discharge, and the BOM was helping with discharges. During an interview on 12/31/24 at 9:19 a.m., NF1 said resident #47 was discharged home to a small town in rural Montana. NF1 said the facility sent some of his medications home when discharged , but not all of them, because the pain patches were not received. NF1 said resident #47 was not receiving…

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 provide evidence for the reporting, investigation, and follow up actions taken to protect residents, for an allegation of a resident-to-resident verbal abuse to the State Survey Agency for 4 (#s 6, 11, 20 and 32) of 25 sampled residents. Findings include: 1. Review of a Facility-Reported Incident, dated 12/4/23 and submitted to the State Survey Agency reporting system on 12/4/23, showed there was a verbal assault between resident #20 and his roommate, resident #32. The report showed resident #20 verbally threatened to kill resident #32, causing resident #32 to be fearful of staying in their shared room. The report showed resident #32 was removed from the room for safety. The facility investigation documentation was requested on 7/1/24 related to the 12/4/23 resident-to-resident verbal altercation, and no documentation or report of findings was received by the end of the survey period on 7/3/24. 2. Review of a Facility-Reported Incident, dated 1/16/24 and submitted to the State Survey Agency reporting system on 1/16/24,…

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 medication error rates were under 5%, which affected 2 (#s 1 and 8) of 4 residents sampled for medication administration. The calculated medication error rate was 15%. Findings include: 1. During an observation on 7/2/24 at 7:43 a.m., staff member N administered the following medication to resident #1: - Staff member N dispensed a one gram tablet of Sodium Chloride. The physician's order was for a two gram total dose. The surveyor questioned staff member N on the amount of Sodium Chloride dispensed, and staff member N pulled an additional one gram tablet of Sodium Chloride from the bottle, for administration to resident #1. 2. During an observation on 7/3/24 at 8:26 a.m., staff member H administered the following medication to resident #8: - Insulin Glargine injection, 100 units/milliliter, 38 units subcutaneously - Insulin Aspart injection,100 units/milliliter, three units subcutaneously Staff member H did not prime the Aspart or Glargine insulin pens prior to administration. A review of the…

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

Based on observation, interview, and record review, the facility failed to sufficiently staff the dietary department with the necessary staff to carry out the normal functions of the department. This deficient practice had the potential to affect all residents served meals by the dietary department, by causing meals to be served late, and not meeting resident preferences. Findings include: During an interview on 7/1/24 at 11:10 a.m., NF3 stated there were some identified concerns with staffing and food; mostly dietary staffing and late mealtimes. During an observation on 7/1/24 at 12:35 p.m., the noon meal was supposed to be served at 12:00 p.m. and had not been served to the residents. There were residents in the dining room waiting for the meal to be served. During an observation on 7/1/24 at 12:53 p.m., the staff announced over the intercom that lunch was ready and being served. Staff started serving the residents in the dining room at this time. During an interview on 7/1/24 at 2:33 p.m., NF2 stated she had noticed the meals were being served late. During an interview on 7/1/24…

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 obtain a medication self-administration physician's order prior to leaving medications at a resident's bedside, for 1 (#4) of 4 residents sampled for medication administration. Findings include: During an observation and interview on 7/2/24 at 7:50 a.m., staff member N left a medicine cup with two Cephalexin 500 mg capsules at resident #4's bedside table for self-administration. In response to whether resident #4 had a current order for self-administration of medications, staff member N stated, Oh, I guess I shouldn't have done that. Staff member N then returned to resident #4's room and observed her taking the medication. Review of resident #4's medical record failed to show a medication self-administration order.

Based on interview and record review, the facility failed to report a major injury that was not witnessed, and there was not a reliable source for the cause of the injury, to the State Survey Agency, for 1 (#6) of 2 residents sampled for injuries. Findings include: Review of resident #6's medical record showed resident #6 was found on the floor in her room by staff on 5/22/24 at 2:45 a.m., complaining of pain and was transported to the hospital. Resident #6 told the staff she needed to use the bathroom. The medical record did not show when resident #6 was last observed or toileted. Resident #6's most recent MDS assessment,with an ARD of 6/6/24, showed resident #6 had a BIMS (Brief Interview for Mental Status) score of two, showing low level cognitive function and recall, and the resident was not a reliable reporter. Review of the physician hospital discharge summary note, dated 5/31/24, showed resident #6 was diagnosed with a pelvic fracture, and experienced significant blood loss, requiring intravenous fluids, three blood transfusions, and evacuation of a large hematoma 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 and record reviews, the facility failed to provide residents or their representatives with a summary of their baseline care plan for 3 (#'s 14, 144, and 145) of 6 residents sampled for baseline care planning. Findings include: During an interview on 7/1/24 at 2:33 p.m., NF2 stated, (Resident #145) hasn't been in this facility that long, and I'm not sure what his plan of care is. During an interview on 7/1/24 at 2:41 p.m., resident #144 stated, I haven't participated in a care plan. I would like more therapy to gain strength to go home. No one has talked to me about discharge; I don't know what the plan is. During an interview on 7/1/24 at 3:27 p.m., resident #14 stated, The facility hasn't talked to me about my plan of care. I do know that therapy is helping; I'm seeing progress in my legs. During an interview on 7/3/24 at 7:59 a.m., staff member G stated, Social services usually invites the resident and representatives to the care plan meetings and obtains the signatures on the baseline care plan. Staff member G stated they are trying to get electronic…

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 identify if a wound was unavoidable or not, and the facility failed to ensure proper wound care treatments were performed for 1 (#8) of 1 sampled resident for wound care. Findings include: During an interview and observation on 7/3/24 at 12:22 p.m., resident #8 had a dressing to her right lower shin that showed a date of 6/30/24 at a time of 2030 (8:30 p.m.). The physician's order showed to change the dressing every other day. Staff member H removed the old dressing to the right lower shin wound which showed no calcium or silver alginate on the dressing. Staff member H stated she did not think she saw calcium or silver alginate in the dressing she was removed. The wound characteristics upon observation were: a shallow open wound about the size of a dime; the wound bed was red in color; the surrounding tissue was pink and moist with loose intact skin on the superficial surface; no observation of fascia, muscle, bone, or slough. Review of resident #8's physician order showed, Wound care to Right Shin: Cleanse…

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 proper management of the communal resident personal food refrigerator and freezer. Findings include: During an interview and observation on 7/1/24 at 11:24 a.m., staff member E stated her department was not responsible for monitoring the resident personal food refrigerator. Staff member E was unsure who cleaned or who monitored the temperatures to ensure the food was stored safely in the communal resident personal refrigerator and freezer. Staff member E stated she assumed nursing staff or maintenance staff were responsible for these duties. The resident personal food refrigerator and freezer did not have temperature logs located on the outside of the doors. The other freezers and refrigerators in this room that were used by kitchen staff had temperature logs showing daily temperatures were completed. In the resident personal food refrigerator, half of a piece of fruit was wrapped in a paper towel. This item was not in a closed container and was not dated. The fruit was located in a plastic bag with 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 interview and record review, the facility failed to maintain complete medical records, including physician progress notes, for 5 (#14, 24, 29, 31 and 85) of 5 residents sampled. Findings include: 1. Review of resident #24's EMR, accessed 6/5/23 - 6/8/23 showed a lack of physician notes, including admission or progress notes. Resident #24 was admitted to the facility in March of 2023. He had two hospital readmissions between his facility admission, and the recertification survey 6/8/23. 2. Review of resident #29's EMR, accessed 6/5/23 - 6/8/23 showed a lack of physician notes, including admission or progress notes. Resident #29 was admitted to the facility in March of 2023. During an interview on 6/6/23 at 8:44 a.m., staff member C stated there were no physician progress notes scanned into the charts. She stated they would have to request them from the hospital as they were no longer being automatically sent to the facility. She stated this had been going on for a while, around the time of Covid-19. 3. Review of resident #31's EMR, accessed 6/5/23-6/8/23 showed no physician…

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 maintain a facility-wide infection prevention and control program. This deficient practice had the potential to affect all residents in the facility. Findings include: 1. During an interview on 6/7/23 at 2:44 p.m., staff member B stated staff member K was helping her with the infection control and prevention program data for a while, but since then has had no assistance, and the program is a lot. Staff member B stated staff member K was not certified for infection control but was helping with it. Record review shows an infection preventionist certificate for staff member B, dated 5/8/23. Infection control logs are signed as completed by staff member K and co-signed by staff member B dating back to January 2023, which was the earliest infection control log available for review. 2. Infection prevention and control program record review showed infection control logs were missing for June 2022 through December 2022. Infection prevention and control program record review also showed incomplete and inaccurate infection control…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's room was kept clean and hazard-free as needed, and this bothered the resident, for 1 (#4) of 6 sampled residents; and failed to keep common areas of the facility clean and homelike. Findings include: 1. During an observation and interview on 6/5/23 at 12:58 p.m., resident #4's bathroom toilet was soiled with urine and feces on the outside of toilet. The sink was heavily soiled with brown matter. The window blind had multiple brown spots, and the window sill had heavy grime. Resident #4 stated the window blind was broken, but she had notified maintenance so it would be fixed. Resident #4 stated that housekeeping only cleaned the resident's room occasionally, but not every day. Resident #4 stated she was not happy with the way things were cleaned. During an interview on 6/7/23 at 10:00 a.m., staff member NF5 stated that resident rooms were cleaned daily, which included sweeping, mopping, and spot cleaning the walls. During an observation and interview on 6/8/23 at 9:56 a.m., resident #4'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 record review, facility staff failed to ensure a resident's MDS (Minimum Data Set) assessment information was complete and accurate for 1 (#85) of 4 sampled residents. Findings include: Review of resident #85's Quarterly MDS, with an ARD (Assessment Reference Date) of 6/21/22, showed the resident's weight as 106 lbs. Review of resident #85's medical record, showed the resident's weight as 99.2 lbs. on 4/1/22. There was no weight recorded for May 2022, and the next weight documented was on 6/28/22, and was 98 lbs. Review of resident #85's Quarterly MDS, with an ARD of 9/18/22, showed the resident's weight as 106 lbs. Review of resident #85's medical record, showed the resident's weight as 97.2 lbs. on 7/6/22, and 98.8 lbs. on 8/3/22. Review of resident #85's Quarterly MDS, with an ARD date of 12/19/22, showed the resident's weight as 106 lbs. Review of resident #85's medical record, showed the resident's weight on 10/4/22 as 101.2 lbs. For the month of November 2022, the ordered weight frequency was increased to weekly, effective 11/4/22. Resident #85's weights…

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 consistently complete the ADL task of facial hair removal for 1 (#31) of 6 sampled residents. This deficient practice caused the resident to be embarrassed when leaving her room, fearing others would be able to detect her long chin hair. Findings include: During an interview and observation on 6/5/23 at 1:27 p.m., resident #31 stated she received a shower on her scheduled days, which were two times a week, but had asked the nursing staff if they would please remove her chin hair. Resident #31 said the staff never returned to remove the hair. Resident #31 stated she was embarrassed to leave her room, and prior to coming to the facility she would have never left her home looking like that. Resident #31 had visible chin hair growth and it appeared to make the resident feel embarrassed during the interview. During an interview and observation on 6/7/23 at 9:26 a.m., resident #31 was in her room sitting in her recliner, and she did not appear to have any visual chin hair. Resident #31 stated that her friend had come to see her 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 interview and record review, the facility failed to ensure residents received timely wound care services, consistent with professional standards, for 1 (#24) of 2 sampled residents. Findings include: Review of resident #24's nursing progress notes, dated 3/28/23, showed, . stage one pressure ulcer noted to coccyx. Review of resident #24's skin evaluation, dated 3/30/23, showed he had a Stage two pressure ulcer to his coccyx. This skin evaluation was documented as the first observation of the wound. Review of resident #24's physician orders did not show any wound care orders until 4/10/23. Review of resident #24's nursing progress notes, dated 4/10/23, showed, . all parties were notified. Notify MD of any changes to the wound. During an interview on 6/6/23 at 11:11 a.m., NF2 stated there had been struggles getting resident #24 to see a doctor in the facility. During an interview on 6/8/23 at 10:06 a.m., staff member B stated she also could not find any wound care orders for resident #24 prior to the 4/10/23 dated order. She stated she knew they were putting barrier cream 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 observation, interview, and record review, the facility failed to ensure pain management services were provided to residents in accordance with professional standards and the resident goals and preferences for 2 (#s 31 and 90) out of 2 sampled residents. Findings include: 1. Review of a Facility Reported Incident, dated 6/29/22, showed resident #90 fell while transferring from her wheelchair into her recliner. She sustained four fractured ribs. Review of resident #90's physician orders after the fall showed, Oxycodone 5mg, give 2.5mg every four hours as needed for pain. Review of resident #90's nursing progress notes, dated 7/29/22, showed, Fax #3 sent this a.m. to [provider name] to try and obtain pain medication for [resident #90] who rates her pain in her ribs the left side 8/10 this morning . 6 attempts have been made to get a hold of [provider name] since 7/26/22 . she has NOT had pain meds, other than Tylenol for her pain since 7/26/22 . [sic] Review of resident #90's MAR showed she last received prn Oxycodone pain medication on 7/26/22 at 5:45 p.m. The next dose 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.