St Mary's Center For Rehabilitation & Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint: NJ170170; NJ169828 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for a resident that had repeated falls. This deficient practice was identified for 1 of 2 Residents (Resident #347) reviewed for falls and was evidenced by the following: On 12/03/2024 at 11:40 AM, the surveyor requested all accidents and/or investigations from the facility for Resident #347 during the year of 2023. The facility provided fall investigations for incidents that occurred on 2/27/23, 4/23/23, and 4/28/23. Upon review of document titled, Incident Audit Report (IR) dated 2/27/2023 at 4:00 PM revealed under Nursing Description: Called to room [ROOM NUMBER] by CNA [Certified Nursing Assistant] and noted resident sitting on floor next to bed. Identified under Resident Description revealed: Resident said [they were] getting up from [their] bed to go the bathroom and fell to the floor. 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, record review, and review of pertinent facility documents it was determined that facility staff failed to use appropriate infection control practices, specifically by failing to wear a gown during high-contact activity in a resident's room who was under Enhanced Barrier Precautions. The deficient practice was identified for 1 of 3 residents (Resident # 190) reviewed for Respiratory Care. The deficient practice was evidenced by the following: A review of Resident # 190's Order Summary located in the Electronic Medical Record (EMR) revealed an order for, Enhanced Barrier Precautions every shift for [catheter]/wound. The order continued, Enhanced Barrier Precautions (EBP) adherence during high contact resident activities. Must wear Gown & Gloves during: Dressing, Bathing, Transfers, Linen changes, Providing hygiene, Brief changes, toileting assistance, indwelling medical device care, and wound care. DON/DOFF and cleanse hands before and after care . A review of Resident # 190's Care Plan located in the EMR revealed an intervention to, Maintain Enhanced…

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 REPEAT DEFICIENCY Complaint # NJ 159503, NJ 160417, NJ 162667 Based on observation, interview, and review of facility documentation it was determined that the facility failed to consistently serve foods at safe and appetizing temperatures. This deficient practice was identified for 2 of 2 units reviewed and was evidenced by the following: 1. On 10/05/23 At 12:25 PM, the surveyor observed large stainless trays with lunch food arrive to the day room one steam table. There were 13 residents seated in day room one waiting for lunch to be served. All of the other unit residents from the first floor had lunch in their rooms. The food service staff began making lunch trays from the steam table. As the trays were being prepared for the residents some trays were handed to the residents in day room one and other trays were placed on a silver open tray cart to be distributed to resident rooms. Trays were placed on the cart for delivery to rooms prior to all of day room one residents receiving their trays. On 10/05/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement Program's (QAPI) sources of quantitative data was being analyzed to evaluate program effectiveness and implement new processes. This deficient practice was identified during the standard survey and was evidenced by the following: Refer to F 804 F During the standard survey, the surveyors conducted meal observations on 10/5/23 and on 10/10/23. On 10/5/23 beginning at 12:25 PM, the surveyor observed the lunch service in day room one. The surveyor observed the lunch tray preparation begin at 12:25 PM, and ended with the last lunch tray served at 1:05 PM. During the observation, some trays were handed to the residents in the day room one, and some tray were placed on an open tray cart to be delivered to the resident rooms. On that same day at 12:45 PM, the open food cart contained the resident lunch trays and left the day room and were placed…

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 review of pertinent documents, it was determined that the facility failed to monitor and document the amount of fluids administered on a resident on hemodialysis with fluid restriction. This deficient practice was identified for 1 of 2 residents reviewed for dialysis, Resident #171, and was evidenced by the following: On 10/04/23 at 12:09 PM, the surveyor observed Resident #171 in their room and observed an unmarked white cup with a lid on the overbed table. The resident stated the cup contained water and would drink the water but not too much. The resident opened the cup and showed surveyor the contents of the cup. The resident further stated that they received hemodialysis three times a week and was also on a fluid restriction. The surveyor observed a picture of a water pitcher taped next to Resident #171's room number and name on the door. On 10/04/23 at 12:12 PM, the surveyor interviewed the Certified Nurses Aide (CNA #5) who stated the water pitcher on the resident's…

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

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to a.) properly label, date and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and dishware in a manner to prevent microbial growth and cross contamination and c.) ensure activity staff were wearing hair nets when entering the kitchen. This deficient practice was observed and evidenced by the following: 1. On 10/03/2023 at 09:45 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the Assistant Food Service Director (AFSD) attempt to remove two boxes of croissants that were not properly labeled with open or discard dates. The first box contained 7 unwrapped croissants and the second box was unopened and did not include a received or a discard date. The surveyor interviewed the AFSD, who confirmed that the 2 boxes of croissants were being discarded because they were not properly labeled. In the walk-in refrigerator, there was a large…

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 review of other facility documentation, it was determined that the facility failed to a.) practice appropriate hand hygiene between residents after direct contact with residents during meal service on 1of 2 units (day room [ROOM NUMBER]) b.) perform hand hygiene when handling a contaminated item from the floor on 1 of 2 units (day room [ROOM NUMBER]) and c.) ensure that a urinary catheter drainage bag was stored in a manner to prevent the spread of infection forone of five residents reviewed for urinary catheters and urinary tract infections (UTIs), Resident #137. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:13 PM, the surveyor observed meal service on the second floor day room [ROOM NUMBER]. At 12:13 PM, the surveyor observed the food truck arrived on the second floor day room [ROOM NUMBER]. At 12:14 PM, the surveyor observed a certified nurses aide (CNA) #6 assisting 4 unsampled residents with hand hygiene using hand wipes. CNA #6 proceeded to…

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

Based on observation, interview, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promoted his/her quality of life for a.) a resident whose preference was to attend church services and was not provided their breakfast tray in a timely manner for 1 of 35 residents (Resident #108) and b.) a resident whose preference was to get out of bed was not honored 1 of 35 residents, (Resident #55) reviewed for Resident Rights. This deficient practice was evidenced by the following: 1. On 10/4/23 at 12:34 PM, during the lunch meal observation on the second floor day room, Resident #108 stated that they didn't receive their breakfast tray until 9:30 AM yesterday morning, which made them late for church. Resident #108 stated that they were uncomfortable going into church late and felt bad holding up the transportation staff. A review of the resident's admission Record revealed that the resident had diagnoses that included but were not limited to Atrial Fibrillation, hypertension, and difficulty walking. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint # NJ 159668 Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to maintain the call bell within reach for two of thirty-five residents (Resident #19) and (Resident #82) reviewed for accommodation of needs and was evidenced by the following: 1. A review of Resident #19's admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia, diabetes mellitus, bipolar disorder, and unsteadiness on feet. A review of Resident #19's Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/12/23, indicated Resident #19 was cognitively impaired, and required supervision of one staff for bed mobility and transfers. On 10/11/23 at 9:01 AM, the surveyor observed Resident #19 seated in a wheelchair by the left side of the bed with the call bell wrapped around the upper right side rail. On 10/11/23 at 10:26 AM, the surveyor…

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, record review, and review of pertinent documentation, it was determined that the facility failed to inform, and provide written information to all adult residents concerning the right to formulate an advance directive. This deficient practice was identified for 1 of 35 residents reviewed (Resident #19) and was evidenced by the following: 1. On 10/11/23 at 9:01 AM, the surveyor observed Resident #19 seated in a wheelchair next to the left side of the bed. The resident greeted the surveyor with a smile. On 10/11/23 at 11:55 AM, the surveyor and Nursing Assistant (NA) observed Resident #19 lying in bed with their eyes closed. On 10/12/23 at 9:26 AM, the surveyor observed Resident #19 seated in a chair eating breakfast. A review of the resident's admission Record reflected that the resident was admitted to the facility with diagnoses which included, but were not limited to, dementia, diabetes mellitus, bipolar disorder, and unsteadiness on feet. A review of Resident #19's Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management…

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, medical record review (MR), and other pertinent facility documentation, it was determined that the facility failed to report an an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 2 residents reviewed for accidents and incidents (Resident # 57). This deficient practice was evidenced by the following: On 10/3/23 at 11:42 AM, the resident was observed sleeping in bed with face partially covered by blanket. Resident #57 did not acknowledge surveyor's presence. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted with diagnosis which included Atherosclerotic Heart Disease (buildup of fats, cholesterol, and other substances in and on the artery wall). A review of Resident #57's Quarterly Minimum Data Set (MDS), an assessment tool, dated 9/15/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) of score of 6 out of 15, which demonstrated severe cognitive impairment. A review of the care plans for Resident #57 identified that the resident had a history 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 interviews, record review, and other pertinent facility documentation, it was determined that the facility failed to timely and thoroughly investigate an injury of unknown origin for 1 of 2 residents reviewed for accidents and incidents (Resident # 57). This deficient practice was evidenced by the following: On 10/3/23 at 11:42 AM, the resident was observed sleeping in bed with face partially covered by blanket. Resident #57 did not acknowledge surveyor's presence. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted with diagnosis which included Atherosclerotic Heart Disease (buildup of fats, cholesterol, and other substances in and on the artery wall). A review of Resident #57's Quarterly Minimum Data Set (MDS), an assessment tool, dated 9/15/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) of score of 6 out of 15, which demonstrated severe cognitive impairment. A review of the care plans for Resident #57 identified that the resident had a history of falls with interventions included but…

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, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care for 2 of 35 residents, (Resident's #79 and #249) reviewed resident assessment. This deficient practice was evidenced by the following: 1.A review of Resident #79's admission Record reflected that the resident had diagnoses which included but were not limited to; dementia and nutrtional deficiency. A review of Resident #79's progress notes written by a wound care Nurse Practioner on 8/15/2023 at 12:38 PM revealed that the resident was seen for a sacral area wound that was identified as moisture associated skin damage MASD. A review of Resident #79's Quarterly MDS dated [DATE] revealed that on Section M1040 (other ulcers wounds and skin problems) M1040H, MASD was not checked as coded. According to Centers for Medicare and Medicaid Services (CMS) Long-Term 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 observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident's preferred gender and name. This deficient practice was identified for 1 of 35 residents (Resident #146) reviewed for care plans and was evidenced by the following: On 10/3/2023 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager(LPN/UM #3), who reported that Resident #146 had a preferred gender and name. On 10/4/2023 at 12:14 PM, the surveyor observed the resident seated in a reclining chair at a table identified as Table 2, which identified Resident #146 with their non-preferred name. On 10/10/23 at 11:26 AM, a surveyor overheard a staff member repeatedly calling Resident #146 by their non-preferred name. On 10/11/23 at 9:08 AM, the surveyor observed that the name tag outside Resident #146's room identified their non-preferred name. The surveyor reviewed the medical record for Resident #146: A review of the admission Record face sheet (an admission summary)…

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 Complaint # 159668 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to obtain a physician's order (PO) for a resident who was transferred to the hospital. This deficient practice was identified for 1 of 4 residents reviewed for hospitalization (Resident #249) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, 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 observations, interview, and record review it was determined that the facility failed to a.) document and monitor a resident that had an external defibrillator life vest (an external device worn on the chest to stop an abnormal heart rhythm), and obtain physician orders for monitoring of a resident's life vest and b.) follow a physicians order for daily wound dressing changes. This deficient practice was identified for Resident #396, 1 of 1 resident reviewed for life vests and Resident #398 1 of 3 residents reviewed for wound care and was evidenced by the following: 1.On 10/03/23 at 10:35 AM, during the initial tour of the facility the surveyor observed Resident #396 in the bed. Resident #396 told the surveyor he/she came to the facility for therapy following angioplasty (unblocking of a blood vessel) for the leg. During the observation the surveyor noticed a small cardiac monitor on the nightstand. A review of the admission Record revealed the resident was recently admitted to the facility with medical…

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 Complaint # 159668 Based on record review, staff interviews, and facility policy review, the facility failed to ensure a newly identified area of skin breakdown was assessed and treated in a timely manner for 1 of 3 residents (Resident #249) reviewed for pressure ulcers and was evidenced by the following: The surveyor reviewed the medical record for Resident #249. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Atrial Fibrillation. A review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 5/17/23, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which demonstrated moderately impaired cognition. The MDS also identified Resident #249 as receiving Hospice Services. A review of the individualized comprehensive care plan (ICCP) for Resident #249 identified a significant change secondary…

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, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order. This deficient practice was identified for 1 of 1 resident (Resident #137) reviewed for respiratory care, and was evidenced by the following: On 10/03/23 at 10:41 AM, the surveyor observed Resident #137 resting in bed watching television (TV). The resident was receiving humidified oxygen by nasal cannula (NC) from a concentrator, which the surveyor observed to be set to 1.5 liters per minute (lpm). On 10/04/23 at 11:19 AM, the surveyor observed Resident #137 sitting in a wheelchair in their room watching TV. The resident was receiving oxygen by nasal cannula with the oxygen concentrator set to 1.5 lpm. The resident informed the surveyor that they did not adjust the oxygen setting themselves, and that the facility nursing staff check on it every now and then. On 10/11/23 at 9:20 AM, the surveyor observed the resident eating breakfast in bed with the oxygen concentrator set to deliver…

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.

Complaint # NJ 155924 Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure: a.) the accurate documentation of the administration of controlled medication for one unsampled resident (unsampled Resident #4) identified upon inspection of 1 of 8 medication carts (Rose Garden cart #1), b.) the shift to shift controlled medication count record was completed for 1 of 8 medication carts, (Rose Garden cart #2), c.) accurate documentation for the destruction of controlled medication for one unsampled resident (unsampled Resident #5) identified upon inspection of 1 of 8 medication carts (Rose Garden cart #2), and d.) medication was received timely from the provider pharmacy 1 of 35 residents (Resident #246) reviewed. These deficient practices were evidenced by the following: 1. On 10/12/23 at 11:10 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #4) inspected the [NAME] Garden cart #1. The surveyor and LPN #4 reviewed the controlled medications located in the secured and locked controlled medications box.…

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.

Complaint # 159668 Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was provided water consistent with the need to maintain resident hydration. This deficient practice was identified for 1 of 1 resident (Resident #59) reviewed for choices and was evidenced by the following: On 10/03/2023 at 11:08 at 10:56 AM, the surveyor observed the resident seated in a wheelchair by the doorway. Resident #59 stated that they were not offered water and had to request water that day. When asked if water was offered throughout the day, Resident #59 denied. On 10/04/2023 at 11:46 AM, the surveyor observed the resident sitting by the doorway of their room. There was no water cup at the resident's bedside. The resident stated that they had requested water and did not get any that day. The surveyor reviewed the medical record for Resident #59. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included failure to thrive, muscle wasting, 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.

Complaint # 159668 Based on interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by not documenting pertinent clinical documentation on the resident's medical record for a resident who was transferred to the hospital. This deficient practice was identified for 1 of 4 residents (Resident #249) reviewed for hospitalization and was evidenced by the following: The surveyor reviewed the medical record for Resident #249. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Heart Failure, Chronic Obstructive Pulmonary Disease, and Chronic Atrial Fibrillation. A review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool dated 5/17/23, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which demonstrated moderately impaired cognition. The MDS also identified 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.