Oakland Rehabilitation And Healthcare Center

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure residents received timely and appropriate incontinence care to achieve their highest practical wellbeing. This deficient practice was identified for 1 of 2 residents, Resident#113, reviewed, and was evidenced by the following: On 5/22/25 at 11:00 AM, the surveyor observed Resident#113's door was closed with a linen cart outside the door. Inside the resident's room, there was a strong smell of urine. The surveyor observed a Certified Nursing Aide (CNA) providing incontinence care to Resident#113. The CNA showed the resident's soaked incontinence brief. On that same date and time, the CNA informed the surveyor that when she arrived at 7:00 AM, for her 7:00 AM to 3:00 PM (7-3) shift, she did not have a chance to provide incontinence care to the resident until now, at 11:00 AM, because she had a lot of residents on her assignment. The CNA was unable to say how many total residents she had on her…

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 review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate documentation of the receipt of a controlled substance for 13 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on 3 Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) out of 15 reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. 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 and 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…

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.

3. On 5/28/25 at 8:54 AM, Surveyor#2 (S#2) observed Licensed Practical Nurse#2 (LPN#2) assigned to the med cart (med-cart) located on the 2nd Floor, prepare and administer due meds to Resident #162. S#2 observed LPN#2 prepare and administer ferrous sulfate 325 mg (iron, a med that is a mineral used to treat anemia or low iron in the blood) and calcium carbonate 500 mg with vitamin D 200 u (unit) (calcium, a med that is a mineral used to treat low blood calcium and strengthen the bones along with the resident's other meds). Both the iron and calcium were scheduled to be given at 9:00 AM per the PO. S#2 asked LPN#2 if there were any drug interaction warning in the eMAR for the calcium or iron. LPN#2 could not locate any interaction warnings. S#2 asked LPN#2 if there were any drug interaction warnings on the containers for iron or calcium. LPN#2 and S#2 could not locate any warnings about the interaction on the med container labels. S#2 asked LPN#2 if they were aware that iron and calcium can interact if given at the same time. LPN#2 stated they were not aware of the interaction 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.

Based on observation, interview, and record review, it was determined the facility failed to follow a physician's order for medications with a parameter and acceptable professional standards of practice for 1 of 28 residents, Resident#54, reviewed. The deficient practice is 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 and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 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 licensed practical nurse is defined as performing…

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 properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 5 medication carts observed on 1 of 4 nursing units of the facility. This deficient practice 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 5/27/25 at 12:34 PM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following: The surveyor in the presence 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.

Complaint # 172385 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were accurate and easily accessible. This deficient practice was evidenced by the following: On 5/22/25 at 1:32 PM, the surveyor requested from the Director of Nursing (DON) the Certified Nurse Assistant (CNA) unit assignment sheets for the facility's 4 units for the day shift for 3/19/24, 3/20/24, and 3/21/24. On 5/23/25 at 12:13 PM, the facility provided a computer printout of the staff in the facility for 3/19/25, 3/20/25, and 3/21/25. The surveyor requested from the Licensed Nursing Home Administrator (LNHA), the CNA assignment sheets for the facility's 4 units for the day shift for the three dates. On 5/29/25 at 12:50 PM, the surveyor notified the LNHA that the CNA assignment sheets that were provided to the surveyor were for the year 2025, and not the requested 2024. On 5/30/25 at 10:00 AM, the surveyor requested from the LNHA the CNA assignment sheets. On 5/30/25 at 10:18 AM, the LNHA provided…

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 other pertinent facility documentation, it was determined that the facility failed to follow appropriate use of personal protective equipment (PPE) and the physician's order for Enhanced Barrier Precautions (EBP). This deficient practice was identified on 1 of 1 contracted staff (Hospice Aide), failed to follow appropriate infection control practices to prevent the spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, revealed, EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g.,…

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, record review, and policy review, the facility failed to ensure five residents reviewed for abuse (Resident (R) 1, R5, R13, R14, and R32) out of 32 sampled were free from physical abuse. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 2001, provided by the facility, revealed Residents have the right to be free from abuse . The resident abuse . consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect . by anyone including but not limited to: a. facility staff; . f. family members . 1. Review of R1's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted on [DATE]. Review of R1's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/14/23, located in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure a potential allegation of abuse for two of seven residents reviewed for abuse in the sample of 32 was reported timely to the State Survey Agency (SSA). Specifically, the facility failed to report R1's suspicious bruising of the upper arm and an allegation of physical abuse which involved Certified Nurse Aide (CNA)10 and Resident (R) 5 to the SSA timely. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 2021 indicated, . All reports of resident abuse (including injuries of unknown origin).are reported to local, state, and federal agencies. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies. The state Licensing/certification agency responsible for surveying/licensing…

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, record review, and policy review, the facility failed to ensure a thorough investigation into allegations of abuse for two of seven residents reviewed for abuse (Resident (R) 1 and R5) out of 32 sampled residents. This failure increased the risk of other vulnerable residents for further physical abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, provided by the facility, revealed Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled, and protected from tampering or…

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, record review, document review and policy review, the facility failed to have an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotic was ordered for a urinary tract infection (UTI) in order to reduce the development of antibiotic-resistance organisms for one of three residents (Resident (R) 11) reviewed for UTIs out of 32 sampled residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship revised December 2016, provided by the facility, revealed, Policy Statement Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Policy interpretation and implementation 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents . Review of the Infection Preventionist Job Description, provided by the facility, revealed, Job Summary 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, interviews, and review of facility policy, the facility failed to promote a dignified dining experience when staff served meals to residents who were seated at overbed tables in the hallway for 15 of 55 residents who resided on the facility's Unit 2E. Findings Include During an observation on 02/27/23 at 5:36 PM, staff on the facility's Unit 2E, which included resident rooms from 201 to 231, served meals to residents who were seated in the hallway. Eleven residents, with cognitive impairments, were served and ate their evening meal while seated at an overbed table in the hallway. During an observation on 02/27/23 at 5:40 PM, no residents were eating their evening meal in the facility's 200-hall dining room. During an observation on 02/28/23 from 5:21 PM to 5:31 PM, staff on Unit 2E served meals to residents who were seated in the hallway. Fifteen residents, with cognitive impairments, were served and ate their evening meal while seated at an overbed table in the hallway. During an observation on 02/28/23 at 5:33 PM, no residents were eating their evening meal…

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, record review and policy review the facility failed to ensure that the kitchen was maintained in a sanitary manner for 185 out of 188 residents (3 residents were receiving tube feedings). Specifically, unit pantry refrigerators were found to contain unlabeled food items brought in by residents' family and were observed to have grime and food residue on the inside. Findings include: A tour of the Unit Pantry refrigerators, which was where the residents could store their food from outside, was conducted on 03/01/23 at 1:14 PM with the Food Service Director (FSD.) In the refrigerator on the 2 North (2N) unit, there is a 16 ounce, opened Greek yogurt noted in the refrigerator. The item has a room [ROOM NUMBER]D on it but was not labeled or dated. The Registered Nurse (RN) 4 on the unit, outside the pantry, was interviewed immediately. She stated food items brought in by family Has to have a name and a date on it and if the item is past three days it has to be thrown out. She was not…

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

Based on staff interviews and facility policy review, the facility failed to ensure their designated Infection Preventionist (IP) completed specialized training in infection prevention before assuming the position of infection preventionist. This failure had the potential to affect the residents residing in the facility. Findings include: During the entrance conference at the facility on 02/27/23 at 10:57 AM the Administrator stated the facility's IP February 14, 2023 and had no yet completed specialized infection prevention training. During an interview on 03/02/23 at 2:27 PM the IP stated she had been working on completing the infection control training in the last year and had been the Infection Preventionist in another building during that time. IP was able to complete the training during the survey. During an interview with the Director of Nursing (DON) on 03/02/23 at 2:50 PM she stated it was the terms of her accepting the position (as IP) that she would have to complete it (the training). The DON admitted the training was not completed until after the IP assumed the position.…

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 policy review, the facility failed to ensure one of 35 residents(Resident (R) 179) had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Specifically, R179 was readmitted to the facility to a locked dementia care unit after previously having been admitted to the subacute rehabilitation unit. Findings include: Review of R179's Electronic Medical Record (EMR) under the Profile tab revealed a documented titled, admission Record which indicated R179 was admitted [DATE] with diagnoses including hypertension, lack of coordination, muscle wasting and atrophy and pulmonary embolism. Review of R179's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/18/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact and the MDS indicated the resident showed no behaviors of inattention, disorganized…

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 policy review, the facility failed to complete documentation of residents' wishes for treatment in the Practitioner Orders for Life-Sustaining Treatment (POLST-used as directions to emergency health personnel in the event of cardiac or respiratory failure)) for three of four residents (Resident (R) 116, R393, and R394) reviewed for advance directives in a total sample of 35 residents. This failure created the potential for residents to not have their wishes known should they suffer a health emergency. Findings include: 1.Review of R116's profile, located on the profile tab of the electronic medical record (EMR), revealed R116 was admitted to the facility on [DATE] with diagnoses that included dementia and generalized muscle weakness. Review of R116's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R116 had a Brief Interview for Mental Status (BIMS) score of 99, indicating R116 was cognitively impaired and unable 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 interviews, record review, and policy review, the facility failed to provide a discharge plan and develop a discharge care plan for one of three residents (Resident (R) 112) reviewed for discharge out of a total sample of 37 residents. This failure increased the risk of incomplete discharge planning for residents wanting to be discharged from the facility. Findings include: Review of R112's undated admission Record, under the Profile tab in the electronic medical record (EMR), revealed R112 was admitted to the facility on [DATE] with multiple diagnosis to include acute kidney failure, encephalopathy, and COVID-19. Review of R112's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/23 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R112 was cognitively intact. Review of R112's Social Services Assessment, under the Assessments tab in the EMR and dated 01/26/23, revealed .Discharge Planning: The…

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

Based on interview, medical record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 190) reviewed for closed records had a discharge recapitulation of stay, a medication reconciliation, and a discharge plan of care. This failure has the potential to have any resident that may discharge not have the information required regarding medical appointments, medication regimen, and other information for a successful discharge. Findings include: Review of R190's admission Record from the facility electronic medical record (EMR) Profile tab showed a facility admission date of 01/27/22 with medical diagnoses that included COVID-19, other abnormalities of gait and mobility, and weakness. A review of the Progress Notes from the EMR Prog Notes tab showed, 12/29/22 0:938 Mental Status Questionnaire (MQS) Discharge Summary Social Services. R190 was discharged on 12/13/22 at 4:30PM. The responsible party was the daughter in law and the discharge destination was home. Mode of transportation was private vehicle. Medications were listed 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 record review, interview, and policy review, the facility failed to ensure the attending physician acted upon the pharmacist recommendations for one of five residents (Resident (R)161) reviewed for unnecessary medications out of a total sample of 35 residents. This failure increases the risk that residents will continue to receive unnecessary medications that potentially could cause serious adverse effects. Findings include: Review of the R161's Face Sheet, located on the profile tab in the electronic medical record (EMR) revealed R161 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of colon, kidney disease, and hypertension. Review of Physician Orders, under the Orders tab, revealed R161's medication regimen included the following medications: Amlodipine Besylate Tablet 5 MG-Give 1 tablet by mouth one time a day related to essential (primary) hypertension (used to treat hypertension). Diltiazem HCl Tablet 30 MG-Give 1 tablet by mouth three times a day related 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 observation, interview, record review, and facility policy review, the facility failed to ensure proper injection technique was used for one of one residents (Resident (R) 138) reviewed for insulin during medication administration. This failure had the potential to result in the wrong dose of insulin administered to the resident. Findings include: Review of R138's undated admission Record, under the Profile tab in the electronic medical record (EMR), revealed R138 was admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus without complications. Review of R138's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/23, found in the electronic medical record (EMR) under the MDS tab, revealed R138 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R138 was cognitively intact. The MDS also indicated R138 had a diagnosis of diabetes mellitus (DM) and received seven insulin injections during the last seven days. 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 Based on observation, interview, and record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 32 residents reviewed, Resident#116, and was evidenced by the following: On 3/18/21 at 11:09 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that Resident #116 was cognitively impaired and on hospice care. On 3/18/21 at 11:37 AM, during the tour, the LPN/UM informed the surveyor that the hospice nurse comes to the facility at least 1 to 2 times a week. The resident was seated in a wheelchair in their room. A review of the resident's Face sheet (an admission summary) disclosed that the resident had diagnoses that included Alzheimer's disease, Depression, Hypertension (elevated blood pressure), and Systemic Lupus Erythematosus (a most common type of lupus, is an autoimmune disease in which the immune system attacks its tissues, causing widespread inflammation and tissue damage in 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.