Clayton Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, Nurse Practitioner, and Pharmacist, the facility failed to ensure a nurse knew he was responsible for a newly admitted resident in order that the nurse reconcile what medications had been given to the resident at the hospital, then validate with the facility provider what medications were needed on day of admission to the facility, and administer those medications (Resident # 1). Additionally, the facility failed to ensure nurses were knowledgeable about a newly admitted resident's medical history and could access the medical history when they were assigned to that resident (Resident # 1) and that a resident (Resident # 19) did not miss a dose of a medication ordered four times per day. This was for 2 or 10 residents reviewed for professional standards of practice (Resident #1 and Resident #19).The findings included: 1. Record review revealed Resident # 1 was admitted to the facility on [DATE] after being hospitalized from [DATE] to 9/10/25 with pneumonia, septic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, the facility failed to ensure a diabetic resident who received all of his nutrition by way of enteral feeding (an enteral feeding is a method of providing nutrition for individuals who are unable to eat by mouth and involves using a feeding tube to deliver nutrients and fluids directly into the stomach or small intestine) received enteral feedings as ordered during two consecutive days. This was for 1 of 2 sampled residents who received enteral feedings (Resident #1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE] after being hospitalized from [DATE] to 9/10/25 with pneumonia, septic shock, diabetic ketoacidosis, and encephalopathy. The resident's Discharge summary, dated [DATE], noted the resident had severe dysphagia and had experienced recurrent pneumonia while hospitalized . The resident was made NPO (nothing by mouth) and a gastrostomy tube (the tube inserted into the resident's stomach to provide nutrition)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility Wound Physician and staff interviews, the facility failed to administer four doses of an antibiotic as ordered by the physician for a resident's wound infection. This was for 1 of 7 residents whose medications were reviewed (Resident # 26).The findings included:Resident # 26 was admitted to the facility on [DATE] with diagnoses which included dementia, cerebral infarction (a condition where blood flow to the brain is interrupted), moderate protein calorie malnutrition, and immunodeficiency (a condition in which the immune system is weakened). Resident #26's care plan dated 7/28/25 revealed a focus for pressure ulcer development with the goal of remaining free from infection. The interventions included administering medications and treatments as ordered, and following the facility policies/protocols for treatment/prevention of skin breakdown. Resident #26's significant change Minimum Data Set (MDS) dated [DATE] revealed he was cognitively impaired. Resident #26 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 observation and interview with resident and staff the facility failed to provide palatable food to a resident when a burnt, blackened piece of toast was served to a resident. This was for 1 of 5 residents reviewed for dietary services provided to residents (Resident # 27). The findings included.Resident # 27 was admitted to the facility on [DATE] and had a current diet order for a regular diet. Resident # 27's quarterly Minimum Data Set Assessment, dated 9/12/25, coded the resident as moderately cognitively impaired.On 10/18/25 at 8:45 AM Resident # 27 was observed eating her breakfast meal and had completed a portion of it. She was observed with a piece of toast on her plate which she had not yet eaten. She picked up the toast and both sides were observed black from being burnt. The entire piece of toast was approximately 75 % black. Resident # 27 reported she was going to try to eat it. Resident # 27's roommate spoke up and reported the resident did not need to eat the toast. On 10/18/25 at 8:57 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, Responsible Party interview, and staff interview the facility failed to ensure the dietary electronic system worked in a manner that allowed for a resident to be served her preferences when the preferences were offered on the menu as an option and when the resident had impairment of her communication skills and could not verbally voice preferences when meals were served. This was for 1 of 5 sampled residents reviewed for dietary services (Resident # 4). The findings included:Record review revealed Resident # 4 was admitted to the facility on [DATE] and had a diagnosis of dementia and protein calorie malnutrition.Review of Resident # 4's quarterly MDS (Minimum Data Set) assessment, dated 9/24/25, revealed Resident # 4 was moderately cognitively impaired, had highly impaired hearing, and was non-verbal.Resident # 4's care plan, dated 9/12/25, reveled the resident could communicate by writing.A review of the resident's current diet order revealed Resident # 4 was ordered a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with staff, Nurse Practitioner, Wound Physician, and hospice staff, the facility failed to ensure effective communication and coordination of care occurred with the hospice provider. On 10/17/25 Resident #26 was identified with a wound infection and facility nursing staff attempted to reach the hospice provider's on-call services on 10/17/25 and 10/18/25 to evaluate the resident and determine if an order was needed for an as needed (PRN) pain medication stronger than the resident's active PRN order for acetaminophen to have available to treat potential increased pain resulting from the wound infection. This deficient practice affected 1 of 2 sampled residents reviewed for coordination of hospice services (Resident #26).The findings included:The Hospice Facility and Services Agreement contract dated 8/1/22 stated, .facility shall timely communicate to Hospice all pertinent information concerning each hospice patient including but not limited to (i) a significant…

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

Based on record review and staff interview the facility failed to maintain a kitchen oven in working condition which in turn affected meal delivery times. This was for 1 of 2 kitchen ovens (Oven # 1). The findings included:The Facility Dietary Manager (DM) and a Regional Corporate Dietary Manager were interviewed on 10/16/25 at 5:00 PM and reported the following information. There was only one working oven in the kitchen. According to the Facility DM the problem with the oven started around 9/8/25 or 9/9/25 and had been problematic for over a month. She thought she put a work order in but one of the maintenance employees was not in the facility all the time. They were trying to accomplish cooking multiple items in one oven which made it difficult to stay on scheduled meal delivery times. The DM was aware there had been some complaints about late trays on the 400 hall, which was the last hall to receive trays. On 10/20/25 at 12:40 PM Maintenance Employee # 1 and Maintenance Employee # 2 were interviewed and presented a timeline of events regarding the attempts to get the oven…

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 interviews with resident, staff and the facility's pest control technician, the facility failed to communicate effectively amongst themselves and with their pest control technician regarding locations, extent, and times of live roach sightings in order that a plan be developed to treat and control the roaches. This was for rooms on 3 of 4 of four facility residential hallways (the 200, 300, and 400 hallways) and the service hallway.The findings included:1a. Resident # 5 was admitted to the facility on [DATE]. Review of Resident # 5's 8/6/25 admission Minimum Data Set assessment revealed the resident was cognitively intact. Resident # 5's name also appeared on a list of residents who were considered credible for interview. This was supplied by the facility on 8/19/25.Resident # 5 was interviewed on 8/19/25 at 9:46 AM and again on 8/21/25 at 3:55 PM and reported the following information. On the first day of admission, he had been placed in a room on the 400 hallway. That night he was watching television…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with resident, staff, Physician, Nurse Practitioner, and Pharmacist, the facility failed to provide services to ensure the accurate acquiring, dispensing, and administration of medications for three (Residents # 2, # 5, and #9) of five sampled residents whose medications were reviewed. For Residents # 5 and # 9 the facility failed to acquire and administer medications to newly admitted residents. For Resident # 2 the facility failed to ensure an effective system was in place for the accounting of a medication the resident supplied from home in order that unused medication be returned to the resident and that she not receive another resident's medication at discharge. The findings included: 1. Resident # 5 was admitted to the facility on [DATE]. Review of hospital records revealed that prior to Resident # 5's facility admission she had been hospitalized from [DATE] to 6/19/25 and discharged home. On 6/20/25 Resident # 5 returned to the hospital ED (emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, Nurse Practitioner, and Pharmacist the facility failed to prevent significant medication errors for two (Residents # 5 and #9) of five sampled residents whose medications were reviewed. For Resident # 5 the facility failed to ensure her Insulin, anticoagulant, and neuropathy medications were administered on the evening of her admission. Following the missed neuropathy medication on Resident # 5's admission date, the facility failed to administer the neuropathy medication on seven more occasions during consecutive days for Resident # 5. The facility failed to obtain and administer an antibiotic to Resident # 9. The findings included: 1. Resident # 5 was admitted to the facility on [DATE]. Resident # 5's diagnoses in part included chronic atrial fibrillation, diabetes, and neuropathy. Review of Resident # 5's admission nursing note revealed Resident # 5's admission time was documented to be 3:45 PM on 6/23/25. Review of Resident # 5's admission orders and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with resident and staff, the facility failed to have a system in place to ensure clean linens were available for two (Resident 7 and Resident #8) of eight sampled residents who were interviewed and which resulted in Resident # 8 having no linens to bathe before leaving for an outside appointment. The findings included: Record review revealed Resident # 8 was admitted on [DATE] and her admission Minimum Data Set assessment, dated 4/15/25, coded Resident # 8 as cognitively intact. Record review revealed Resident # 7 was admitted on [DATE] and her admission Minimum Data Set assessment, dated 4/13/25, coded Resident # 7 as cognitively intact. During an interview on 6/30/25 at 12:22 PM with Resident #7, who was Resident # 8's roommate, Resident # 7 reported a problem with having enough linens at times. One of the problems had been that morning and her roommate (Resident # 8) had to leave for an appointment before washcloths were available for bathing. During an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with resident, staff, and the facility's pest control company technician, the facility failed 1) to make sure holes to the exterior were repaired and sealed to prevent pests from entering in her room and 2) ensure multiple doors in common areas in the facility had weather stripping to seal gaps for one (Resident # 12) of one sampled resident who reported unresolved and repetitive pests issues in her room. The findings included: Resident # 12 was admitted to the facility on [DATE]. A review of Resident # 12's quarterly Minimum Data Set assessment, dated 5/27/25, revealed Resident # 12 was cognitively intact. Resident # 12 was interviewed on 7/2/25 at 4:15 PM and reported the following information. Her room had been treated for roaches repetitively since she had arrived and the treatment did not make any difference. She continued to see roaches crawling on her walls and ceilings. They had just treated her room again that day. During the time of the interview, the…

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

Based on observations and staff interviews the facility failed to label and date leftover food items stored in the walk-in refrigerator for one of one walk in refrigerators observed for food storage. This practice had the potential to affect food served to residents. Findings included: On 11/24/24 at 10:38 AM an observation of the walk in refrigerator with the Assistant Dietary Manager revealed a 4 quart clear plastic container with a green lid which contained approximately 2 quarts of whole corn in liquid with no label to identify the contents or the date it was placed in the refrigerator, a 4 quart clear plastic container with a green lid which contained approximately 4 quarts of cooked rice, a 4 quart clear plastic container with a green lid which contained approximately 2 quarts of red colored liquid, a 4 quart clear plastic container with a green lid which contained approximately 1/2 quart of a mayonnaise based salad, approximately ½ of a small cooked ham wrapped in plastic wrap, a large silver container covered in plastic wrap containing whitish liquid, a bowl of fruit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of medication for 2 of 20 residents (Resident #2 and Resident #17)whose MDS was reviewed. Findings included: 1. Resident #2 was admitted to the facility on [DATE]. A review of Resident #2's Medication Administration Record (MAR) for October 2024 revealed documentation aspirin (an antiplatelet medication) 81 milligrams (mg) was administered to Resident #2 on 10/31/24 at 8:00 AM. A review of Resident #2's November 2024 MAR revealed documentation aspirin (an antiplatelet medication) 81 milligrams (mg) was administered to Resident #2 on 11/1/24 through 11/6/24 at 8:00 AM. A review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was not coded for use of antiplatelet medication during the 7 day look back period of the assessment. On 11/26/24 at 8:36 AM an interview with an interview with the MDS Nurse indicated she coded the medication section 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 record review, staff, resident, and family interviews, the facility failed to invite residents to care plan meetings (Resident #40, Resident #16, and Resident #79) for 3 of 3 residents reviewed for care planning. Findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnosis that include stroke, anemia and hypertension. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact. The care plan for Resident #40 was initiated on 8/10/21 and last revised on 9/12/24. An interview with Resident #40 on 11/25/24 at 10:00 a.m. revealed he had not been invited to care planning meetings. Record review revealed no previous care plan meetings scheduled prior to 11/26/24. An interview with the Social Worker on 11/26/24 at 10:12 a.m. revealed Resident #40 had a care plan meeting scheduled for that day. The Social Worker could not locate any previous care plan meetings in her record review. The Social Worker did state her expectation would be that 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, record review, and staff interviews, the facility failed to maintain a medication administration error rate of less than 5% when a nurse failed to prime an insulin pen and failed to administer Tylenol as ordered by the physician. This resulted in an error rate of 8% for 2 of 25 opportunities observed during medication pass. (Resident #95) Findings included: a. Review of the manufacturer's recommendations for the Humalog insulin pen used by the facility dated 7/21/23 revealed the insulin pen was to be primed before each injection. (Priming an insulin pen means to remove the air from the needle and cartridge and ensures the pen is working correctly). To prime the insulin pen, the user was to turn the dose knob to select 2 units, hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, and push the dose knob in until it stopped and read 0 on the dose window. The user should see the insulin at the tip of the needle. If insulin was not observed…

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

Based on observations, record review, and staff interviews the facility failed to implement their infection control policy when Nurse Aide (NA) #1 did not perform hand hygiene during meal delivery and set-up after knocking on the room door, handling the bed control, moving the overbed table and handling bed linens for 1 of 2 NAs observed passing meal trays on 1 of 4 halls. This had the potential to result in the cross contamination of microorganisms (germs) between residents. Findings included: A review of the facility's policy titled Handwashing/Hand Hygiene dated last revised August 2019 revealed in part the following: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 7. Use an alcohol based hand rub containing at least 62 percent alcohol, or alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: l. After contact with objects in the vicinity 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 record review, and interviews with resident and staff the facility failed to provide discharge planning for a cognitively intact resident who was admitted to the facility for short term rehabilitation with the goal to discharge home to her previous residence in the community. Soon after admission, Resident #9 decided she was unhappy at the facility and preferred to receive rehabilitation at home rather than the facility and she voiced her desire to return home to staff. Discharge planning had not been addressed with the resident resulting in the resident leaving the facility with transportation provided by her friend. This was for one of four sampled residents discharged during the week or following the week of the facility's social worker's absence due to illness. The findings included: Resident # 9 was admitted to the facility on [DATE]. Review of Resident # 9's hospital Discharge summary, dated [DATE], revealed the following information. The resident had spinal stenosis and had been identified 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 record review and interviews with staff, family, and physicians, and laboratory employees the facility failed to 1) ensure they identified when a resident initially developed arterial wounds to his feet to ensure the resident received treatment and services at onset of the wounds and 2) recognize a critical hemoglobin level reported to them needed follow up and the lab needed redrawn as ordered by the physician so a determination could be made if the hemoglobin was continuing to drop (Resident # 2). This was for two (Resident # 1 and # 2) of three residents reviewed for medical services being provided per professional standards of care. The findings included: 1. Resident # 1 was admitted to the facility on [DATE] after undergoing surgery for a fractured hip on 7/30/24. Additionally. the resident had diagnoses of dementia, peripheral vascular disease, pulmonary fibrosis, emphysema, chronic kidney disease, benign prostate hypertrophy, hyperlipidemia, anemia, and protein calorie malnutrition. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with resident and staff, the facility failed to identify a resident, for whom they were accountable, was missing from the facility. The resident left the facility and returned home without anyone realizing she was missing until the day following her departure. This was for one (Resident #9) of one resident reviewed for supervision. The findings included: Resident # 9 was admitted to the facility on [DATE]. Review of Resident # 9's hospital Discharge summary, dated [DATE], revealed the following information. The resident had spinal stenosis and had been identified to have a bulging disc resulting in lower extremity weakness and recurrent falls. The discharging hospital physician recommended the resident go to a rehabilitation facility for therapy and the resident was in agreement. Additionally, the resident had diagnoses which in part included a history of stroke without any residual effects, hyperthyroidism, depression, chronic obstructive pulmonary disease, and insomnia.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, pharmacist and physician the facility failed to ensure a resident's medications were available for administration for one (Resident # 9) of one sampled resident reviewed for medication administration. The findings included: Resident # 9 was admitted to the facility on [DATE]. Two of the resident's diagnoses included insomnia and hyperthyroidism. Review of nursing notes revealed Resident # 9 arrived at 5:15 PM on the date of 8/21/24. Review of Resident #9's admission MDS (Minimum Data Set) assessment, dated 8/27/24, revealed the resident was cognitively intact. Review of Resident #9's orders and August 2024 MAR (Medication Administration Record revealed the following information: On 8/21/24 Resident # 9 was ordered to receive Methimazole 10 mg (milligrams) daily for hyperthyroidism. The first dose that was documented as administered was on the date of 8/23/24. Nurse # 6 did not document a check mark on the date of 8/22/24 indicating the methimazole was given. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and the facility's lab company employees, the facility failed to ensure there was effective communication between facility staff and the lab company to avoid a lapse of multiple days between a failed lab draws and the next attempt to obtain a successful lab result for a physician ordered lab. This was for one (Resident # 2) of three residents whose labs were reviewed. The findings included: Resident # 2 was admitted to the facility on [DATE]. The resident's diagnoses in part included stroke, vascular dementia, and anemia. Review of physician orders revealed an order on 8/2/24 for a CBC (complete blood count) to be completed on 8/6/24. On 8/6/24 the resident's CBC result revealed the resident's Hgb (hemoglobin) was a 6.3. The lab result noted this was a critical level. (Normal is 14 to 18). The resident's Hct (hematocrit) was 22.4. (Normal is 42.0 to 52.0). There was also a documentation on the 8/6/24 lab report which noted the lab company had made multiple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview the facility failed to ensure a resident's record accurately reflected a resident's signature on a form indicating the resident left the facility against medical advice. This was for one (Resident # 9) of one sampled resident who had documentation the resident left against medical advice. The findings included: Resident # 9 was admitted to the facility on [DATE]. Review of Resident #9's admission MDS (Minimum Data Set) assessment, dated 8/27/24, revealed the resident was cognitively intact. Review of Resident # 9's orders revealed no discharge orders. Review of the record revealed a form entitled Statement of Resident Releasing Facility from Liability Upon Leaving Facility Against Medical Advice. The form included a signature that was not clearly legible and which appeared by resident signature. It was dated 8/27/24 at 8:57 PM indicating the resident had left the facility against medical advice on the evening of 8/27/24. There were two witnesses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with residents, staff, dialysis staff, transport company staff, and the facility's pest control provider's service technician, the facility failed to ensure a system was in place on three of four halls to ensure ants did not climb into residents' beds or on residents while the pest control company was baiting underground ant colonies while trying to eradicate them. The findings included: 1a. Resident # 1 was admitted to the facility on [DATE]. The resident's diagnoses in part included glaucoma, end stage renal disease for which he went to dialysis three times per week, severe peripheral artery disease, and left foot dry gangrene. Resident # 1 resided on the 400 hall. Resident # 1's quarterly Minimum Data Set assessment, dated 6/17/24, coded the resident as cognitively impaired and as needing substantial to maximum assistance with his hygiene needs. The resident was also assessed to have an arterial wound and as being highly visually impaired. Review of orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, physicians' interview, and interviews with dermatology office staff, the facility failed to follow through in referring a resident to a dermatologist for treatment after the resident was identified to have basal cell carcinoma. This was for one (Resident # 12) of four residents reviewed for professional standards in the provision of medical care. The findings included: Resident # 12 was admitted to the facility on [DATE] with diagnoses which in part included chronic obstructive pulmonary disease and hypertension. The resident's quarterly Minimum Data set assessment, dated 6/7/24, coded Resident # 12 as cognitively intact. Review of Resident # 12' care plan, updated on 3/20/24, revealed the resident had basal cell carcinoma. This had been added to the care plan on 3/20/24 and remained part of the resident's active care plan. The care plan goal was that the resident have no complications from the carcinoma. Staff were directed to provide treatment as ordered.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and pharmacist interview the facility failed to ensure accurate accounting for the dispensing and receipt of 15 tablets of Oxycodone. This was for one (Resident # 5) of one sampled resident whose Oxycodone was reported by the pharmacy as delivered but reported by the facility as not definitively received. The findings included: Resident # 5 was admitted to the facility on [DATE] and resided there until her discharge on [DATE]. Review of physician orders revealed Resident # 5 was ordered Oxycodone 5 milligrams every four hours as needed for pain. This order originated on 2/13/24. Nurse # 7 was interviewed on 2/14/24 at 12:00 PM with the Director of Nursing and reported the following information. Resident # 5's supply of Oxycodone had not been delivered on the routine delivery of 2/13/24 when the resident was initially admitted . Nurse # 7 reported she called the pharmacy on 2/14/24 to order a special early delivery of Resident # 5's Oxycodone. At the time, the facility…

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