Betty Dare Wellness & Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete and transmit a MDS assessment within 14 days of the assessment reference date (ARD; last day of the resident observation period for the MDS assessment) for 1 (R #3) of 3 (R #1, R #2 and R #3) residents reviewed for MDS assessments. This failed practice could lead to the facility not reporting information in a timely manner (within 14 days) to the Centers for Medicare & Medicaid Services (CMS). The findings are: A. Record review of R #3's Quarterly MDS dated [DATE] revealed the following: 1. The ARD was 01/14/26. 2. The RN signed the assessment completion date on 02/10/26. B. On 02/16/26 at 4:50 PM, during an interview, the MDS Coordinator confirmed that R #3's MDS was not completed and transmitted within 14 days.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #3) of 2 (R #3 and R #22) resident reviewed for implementation of orders when the facility failed to: 1. Ensure staff entered convalescent care orders (CCO's, physician-signed, temporary, medically necessary orders to admit a patient to a skilled nursing facility) for oxygen use into R #3's medical record. 2. Ensure staff followed R #3's physician's order for oxygen use. These deficient practices are likely to result in residents not receiving enough oxygen and can lead to worsening of their condition. The findings are: A. Record review of R #3's admission Record, no date, revealed R #3 was readmitted to the facility on [DATE]. B. Record review of R #3's CCO's, dated 02/13/26, revealed an order for R #3 to receive oxygen at a rate of 2.5 liters per minute (LPM, flow rate of oxygen). C. Record review of R #3's orders, no date, revealed staff did not document 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 interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) that include all necessary information for providing care for 1 (R #17) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds. This deficient practice could likely result in residents not receiving the appropriate care upon admission and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition. The findings are: A. Record review of R #17's admission documents, no date, revealed the following:1. R #17 was admitted to the facility on [DATE].2. R #17 had a diagnosis of a fracture (broken bone) of the left femur (upper leg bone), subsequent encounter for closed fracture with routine healing (refers to a specific phase in fracture…

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 interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #16) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #16's admission documents, no date, revealed the following:1. R #16 was admitted to the facility on [DATE].2. R #16 had a diagnosis of a fracture (broken bone) of the left fibula (lower leg bone), subsequent encounter for open fracture type 1 or 2 (indicating a small wound with minimal contamination) with routine healing (the fracture is progressing as expected, without complications like delayed healing or nonunion). B. Record review of R #16's physician orders, dated 11/11/25, revealed the following:1. An order for Surgical Incision (surgical cut made in skin) care for R #16's left inner ankle.2. An order for Surgical Incision care for R #16's left…

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 interview, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 1 (R #16) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds when staff failed to follow physician's orders. If the facility is not providing care per physician's orders, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: A. Record review of R #16's admission documents, no date, revealed the following:1. R #16 was admitted to the facility on [DATE].2. R #16 had a diagnosis of a fracture (broken bone) of the left fibula (lower leg bone), subsequent encounter for open fracture type 1 or 2 (indicating a small wound with minimal contamination) with routine healing (the fracture is progressing as expected, without complications like delayed healing 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 record review, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #16) of 3 (R #16, R #17 and R #18) residents reviewed for treatment of wounds when staff failed to accurately document in the resident's medical record. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: A. Record review of R #16's admission documents, no date, revealed the following:1. R #16 was admitted to the facility on [DATE].2. R #16 had a diagnosis of a fracture (broken bone) of the left fibula (lower leg bone), subsequent encounter for open fracture type 1 or 2 (indicating a small wound with minimal contamination) with routine healing (the fracture is progressing as expected, without complications like delayed healing or nonunion). B. Record review of R #16's physician order, dated 12/03/25, revealed an order to remove R #16's sutures (sterile threads, also called stitches, used 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 the record review and interview, the facility failed to ensure RN coverage was provided for 8 consecutive hours a day and for 7 days a week. This failure could potentially affect all 72 residents who lived in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/23/25. This deficient practice is likely to result in residents not receiving the services they require. The findings are: A. Record review of the Payroll Base Journal (PBJ) Staffing Data Report (report from the database of the federal agency overseeing certification for long term care facilities) dated Quarter #1 (October 1 through December 31) 2025 revealed no RN coverage for at least 8 consecutive hours on 10/06/24 and 12/31/24. B. On 11/21/25 at 2:38 PM during an interview, the administrator confirmed they were unable to provide proof of RN coverage for 10/06/24 and 12/31/24.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #6) of 5 (R #3, R #5, R #6, R #39, and R #60) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: A. Record review of R #6's physician's orders, dated 10/28/25, revealed an order for clonazepam (used to treat seizure disorders and panic disorder) 0.5 mg one time a day for insomnia. B. Record review of R #6's medical record, no date, revealed staff did not document consent for clonazepam. C. On 11/21/25 at 10:19 AM, during an interview, the DON confirmed that there was not a consent for R #6's clonazepam. The DON stated consents should be completed for psychotropic active medications.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless there was adequate monitoring for any adverse consequences resulting from the medication for 3 (R #5, R #6, and R #60) of 5 (R #3, R #5, R #6, R #39, and R #60) residents reviewed for unnecessary medications, when staff failed to: 1. Monitor R #5 for side effects of antidepressant (medication used to treat depression) medication. 2. Perform an AIMS (Abnormal Involuntary Movement Scale test used in medicine to assess side effects of antipsychotic medication) for R #6 and R #60. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #5 A. Record review of R #5's admission documents, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE].…

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 interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representatives in writing for 4 (R #16, R #19, R #83, and R #85) of 4 (R #16, R #19, R #83, and R #85) residents sampled for hospitalizations or discharge when staff failed to: 1. Notify the residents and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R #19 and R #85. 2. Send a written copy of the Discharge or Transfer Notices to the Ombudsman for R #16, R #19, R #83, and R #85. 3. Ensure residents or their representative received a written notice of the bed hold policy which indicated the duration the bed would be held for R #19 and R #83. 4. Complete a discharge summary for R #85. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer or discharge, the location of the transfer or discharge, their rights 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 interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 2 (R #5, and R #39) of 7 (R #1, R #2, R #5, R #8, R #39, R #50, and R #60) residents reviewed for comprehensive care plans (plan that has measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R#5 A. Record review of R #5's admission documents, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5 had the following diagnoses: a. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). b. History of venous thrombosis (blood clot in veins), c. Embolism (obstruction of an artery). B. Record review of R #5's admission MDS, dated [DATE], revealed staff documented that R #5 was taking antidepressant and anticoagulant medication. C.…

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 interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 6 (R #2, R #5, R #6, R #19, R #56, and R #60) of 7 (R #2, R #5, R #6, R #16, R #19, R #56, and R #60) residents when the staff failed to: 1. Ensure the Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participated in a care plan meeting within 7 days of the completion of the MDS assessment for R #5, R #19, and R #56. 2. Revise the care plan with the most current resident information for R #2, R #5, R #6 and R #60. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:…

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 interview, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #70) of 3 (R #16, R #52 and R #70) residents reviewed for nutrition maintained acceptable parameters of nutritional status when staff failed to do the following: 1. Weigh R #70 once weekly for 4 weeks, and monthly thereafter 2. Ensure R #70 received his ordered nutritional supplement. These deficient practices could likely result in resident weight loss and adverse effects. The findings are: A. On 11/18/25 at 9:19 AM, during an interview, R #70's sister stated that the resident was having tooth pain and that she had lost weight because her tooth hurt when she ate. B. Record review of R #70's physicians orders revealed the following: 1. An order dated 10/16/25, R #70 is at risk for weight loss, weigh weekly for 4 weeks and monthly after that. 2. An order dated 10/27/25, house supplement two times a day for poor intake 4 oz. C. Record review of R #70's treatment administration record revealed the following: 1. House shake 4 oz was documented as given only twice,…

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 interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 1 (R #6) of 5 (R #3, R #5, R #6, R #39, and R #60) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: A. Record review of R #6's admission record, no date, revealed the following: 1. R #6 was admitted to the facility on [DATE]. 2. A diagnosis of dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance…

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 interview, the facility failed to ensure staff adequately monitored medications for 1 (R #5) of 5 (R #3, R #5, R #6, R #39, and R #60) residents reviewed for unnecessary medications, when they failed to monitor R #5 for side effects (unwanted effects for medication) of anticoagulant (medicines that help prevent blood clots) medications. If the facility does not adequately monitor side effects of anticoagulant medication, the residents are likely to be at risk of bruising and severe bleeding. The findings are: A. Record review of R #5's admission documents, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5 had a diagnosis of history of venous thrombosis (blood clot in veins) and embolism (obstruction of an artery). B. Record review of R #5's physician orders, multiple dates, revealed the following: 1. An order dated 08/28/25 and discontinued on 09/16/25, for rivaroxaban (medication used to treat and prevent deep venous thrombosis (DVT), a condition…

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

Based on interview and record review, the facility failed to ensure a resident received dental services for 1 (R #70) of 2 (R #6 and R #70) residents reviewed for dental care. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing. The findings are: A. On 11/18/25 at 9:19 AM, during an interview with R #70's Power of Attorney (POA), she stated that R #70's teeth were hurting her, and she doesn't know if R #70 had been to see a dentist. B. Record review of R #70's progress note, dated 07/30/25, revealed R #70 had been to a dentist for an extraction of a tooth and there was decay under the gum. The progress note stated that the tooth broke and that R #70 needed to see an oral surgeon to extract the rest of the tooth. C. Record review of R #70's medical record, no date, revealed there was no documentation that R #70 had been to see an Oral Surgeon. D. On 11/19/25 at 5:25 PM, during an interview, Medical Records (MR) confirmed that R #70 had been to the dentist on 07/30/25 and that there was a referral to see an oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received dental services for 1 (R #6) of 2 (R #6 and R #70) residents reviewed for dental care. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing. The findings are: A. On 11/18/25 at 10:08 AM, during an interview with R #6's son, he stated that R #6 had not been to a dentist since her admission at the facility. B. Record review of R #6's admission record, no date, revealed R #6 was admitted to the facility on [DATE]. C. Record review of a progress note, dated 01/28/25, revealed R #6 was scheduled for a routine dental exam but the dental office canceled the appointment because R #6's insurance was inactive. D. On 11/19/25 at 5:19 PM, during an interview, Medical Records (MR) confirmed that R #6 had an appointment to see the dentist on 01/28/25 but that at the time R #6's insurance was showing as inactive, so the appointment was canceled. MR stated that the dental…

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 interview, the facility failed to ensure medical records were complete and accurate for 3 (R #10, R #24, and R #60) of 4 (R #10, R #24, R #50, and R 60) residents reviewed for documentation accuracy when staff failed to do the following: 1. Document R #24's blood sugar levels. 2. Document R #10 and R #60's activity participation. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: Blood sugar levels R#24 A. Record review of R #24's physician's orders revealed an order dated 03/11/25 for blood glucose level monitoring twice a month on the first and 15th for type 2 diabetes mellitus without complications. B. Record review of R #24's TAR (treatment administration report) revealed the following: 1. For the month of September 2025, R #24's blood sugar levels were not documented. 2. For the month of October 2025, R #24's blood sugar levels were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to have reasonable accommodations for 1 (R #16) of 3 (R #6, R #16, and R #24) residents sampled for accommodation of needs, when they failed to ensure R #16's water was within reach. This deficient practice could likely result in the residents being at risk of accidents and feeling like their preferences and requests are being ignored and lead to feeling like their needs do not matter. The findings are: A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Dementia; b. Muscle Weakness (weak muscles) c. Unspecified fall (fall with unknown cause) B. On 11/17/25 at 1:27 PM, during an observation, R #16 laid down in her bed, revealed the following: 1. R #16's bed was in lowest position. 2. R #16's drinking water was on the bedside table. 3. R #16's bedside table was positioned about two (2) feet from the bed and raised to a level…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #16) of 2 (R #2 and R #16) residents reviewed for falls. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Muscle Weakness (weak muscles); b. Unspecified fall (fall with unknown cause. B. Record review of R #16's progress note, dated 10/13/25, revealed R #16 fell and was transferred to the hospital for evaluation. C. Record review of R #16's admission MDS, dated [DATE], revealed staff documented that R #16 had no falls since admission. D. On 11/19/25 at 2:14 PM, during an interview, the MDS Coordinator confirmed the following: 1. R #16 fell on [DATE]. 2. R #16's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #83) of 3 (R #19, R #49 and R #83) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care upon admission and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition. The findings are: A. Record review of R #83's admission Record (no date) revealed the following: 1. R #83 was admitted into the facility on [DATE]. 2. R #83 had the following diagnoses: a. Encounter for orthopedic aftercare following surgical amputation (healthcare provided after a surgical removal of a limb or other body used to control pain or a disease process…

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, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 1 (R #24) of 1 (R #24) resident reviewed for ADL care when staff failed to: 1. Assist R #24 with nail care. 2. Assist R #24 back to his room after his meal.These deficient practices are likely to affect the dignity and health of the residents. The findings are: Nail Care A. Record review of R #24's admission record, no date revealed the following: 1. R #24 was admitted to the facility on [DATE]. 2. R #2 has a diagnosis of the following: a. Needing assistance with personal care. b. Legal blindness. c. Type 2 Diabetes Mellitus without complications B. On 11/18/25 at 1:01 PM, during an interview with R #24, he stated that his fingernails are too long and they get caught on things. R #24 stated that that he would like staff to cut his fingernails. C. On 11/18/25 at 1:02 PM, during an observation of R #24's fingernails, R #24's fingernails were long and some were jagged and broke. D. 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 and interview, the facility failed to ensure there was a system in place for the nursing staff to immediately determine code status [the residents choice as to whether or not they would like to be provided cardio- pulmonary resuscitation (CPR) in the event that they stopped breathing and/or their heart stopped] for 2 (R #16 and R #55) of 4 (R #16, R #39, R #55, and R #70) residents reviewed for code status. This deficient practice is likely to delay potentially lifesaving measures or cause residents to undergo CPR against their wishes, causing unnecessary suffering. The findings are: R #16 A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE]. B. Record review of R #16's Medical Orders for Scope of Treatment (MOST, designed to ensure that seriously ill or frail patients can choose treatments they want or do not want and that their wishes are documented and honored), dated [DATE], revealed R #16 wanted staff to perform CPR in an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received proper treatment to maintain hearing for 1 (R #1) of 1 (R #1) resident reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot hear, which would compromise their quality of life. The findings are: A. On 11/18/25 at 9:25 AM, during an interview, R #1 said she had experienced hearing loss in her left ear. R #1 stated she has brought up the need to have a hearing evaluation completed but has not been scheduled. B. Record review of R #1's admission Record (no date) revealed R #1 was readmitted to the facility on [DATE]. C. Record review of R #1's Electronic Medical Record (EMR) revealed the following: 1. Care plan conference note dated 07/18/25 Hearing -An appointment is already scheduled. 2. Care plan conference note dated 10/18/25 Hearing - Needs an appointment. D. On 11/21/25 at 3:32 PM, during an interview, the Regional Clinical Nurse (RCN) confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received restorative rehabilitation (focuses on maximizing an optimal level of functioning, enabling clients to regain/retain their independence following the debilitating effects of illness or injury) services as ordered by the physician for 1 (R #20) of 1 (R #20) resident reviewed for rehabilitation services. This deficient practice is likely to result in a decrease in residents' functional mobility. The findings are: A. Record review of R #20's admission record, no date revealed an admission date of 08/22/25. B. On 11/18/25 at 9:44 AM, during an interview, R #20 stated she was supposed to be walking daily with restorative nursing. R #20 stated the RNA (Restorative Nursing Aide) walked her yesterday for the first time in four months because state surveyors were in the building. C. Record review of R #20's physician's orders dated 09/16/25, revealed R #20 may participate in Restorative Nursing Program. Order did not specify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents with a diagnosis of urinary tract infection (UTI) received appropriate treatment for 1 (R #8) of 2 (R #8 and R #70) residents reviewed for urinary catheters (hollow, flexible tube that helps drain urine from the bladder) and UTI when they failed to ensure that a resident received antibiotic treatment for a UTI. This deficient practice could result in residents being susceptible to worsening infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues) The findings are: A. On 11/17/25 at 3:30 PM, during an interview with R #8's son, he stated that R #8 has had a UTI twice since she was admitted . B. Record review of R #8's Electronic Medical Record (EMR) revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8's diagnoses included the following: a. Urinary tract infection site not specified (diagnosis of UTI when the exact location within 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 observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #5) of 1 (R #5) resident reviewed for respiratory care when the facility failed to: 1. Ensure R #5 wore their nasal cannula (a thin, flexible tube that wraps around your head, typically hooking around your ears) correctly. 2. Ensure staff followed the physician's order for oxygen use. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their condition. The findings are: A. Record review of R #5's admission documents, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5 had the following diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD, an ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways). b. Asthma (a chronic lung disease caused by inflammation and…

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

Based on interview and record review, the facility failed to complete performance reviews at least every 12 months for 1 (CNA #1) of 3 (CNA #1, CNA #2, and CNA #3), CNA's sampled for annual performance review. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of CNA #1's personnel records revealed the following: CNA #1's date of hire was 10/01/24. An annual performance evaluation was not completed for CNA #1 in October 2025. B. On 11/21/25 at 2:38 PM during an interview, the administrator confirmed that CNA #1's annual performance was not completed.

Based on observation, and interview, the facility failed to secure medications in a medication cart and a treatment cart for all 61 residents (residents were identified by the census list provided by the Administrator on 07/09/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are:A. On 07/09/25 at 10:03 AM, during an observation of the 100 hallway revealed a medication cart was unlocked. B. On 07/09/25 at 10:08 AM, during an interview, LPN #28 confirmed the medication cart on 100 hallway was left unlocked. LPN #28 also confirmed the medication carts should be locked when unattended. C. On 07/09/25 at 11:50 AM, during an observation of a treatment cart, located across from the nurse’s station in between all floors, was unlocked and was not in staff control. The following medications were in the treatment cart: Aspercreme (pain relief cream used for temporary relief of minor aches and pains), coloplast (related to intimate healthcare needs, including ostomy care, continence care, wound…

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 interview, the facility failed to ensure care plan revisions occurred for 1 (R #1) of 3 (R #1, R #2 and R #3) residents when staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #1's admission Record (no date) revealed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's shower sheet forms dated 02/22/25 through 05/26/25 revealed the following: 1. R #1 was offered showers twelve times. 2. R #1 refused her showers six of the twelve times showers were offered to her. C. Record review of R #1's care plan dated 02/24/25 revealed the following: 1. R #1 requires partial/moderate assistance 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 and interview, the facility failed to notify the provider of R #25's blood pressure medication was not available and had a high blood sugar level greater than 400 (normal range of blood sugar levels of 80-130) for 1 (R #25) of 3 (R #1, R #16 and R #25) residents reviewed for neglect. This deficient practice could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment. The findings are: A. Record review of R #25's admission record (no date) revealed the following: 1. R #25 was admitted to the facility on [DATE]. 2. R #25 had the following diagnoses: a. Essential (Primary) Hypertension. b. Type 2 Diabetes Mellitus without complications. B. Record review of R #25's physician orders, dated 02/13/25, revealed the following: 1. Diltiazem (blood pressure medication) 90 mg oral tablet 1.5 tab oral 2 times per day. 2. Insulin Lispro Injection solution 11 UNIT/ML inject per sliding scale if 0-150=0, 151-200=1, 201-250=2,…

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.

Recite from 08/15/24 Based on observation and interview, the facility failed to provide a homelike environment that was in good condition for 1 (R #1) of 1 (R #1) resident randomly sampled by not repairing the wall behind R #1's bed, ensuring electrical outlets have covers, and removing Velcro stuck onto wall. Failure to maintain and provide a comfortable environment is likely to result in residents feeling unimportant and undervalued. The findings are: A. On 05/29/25 at 12:53 PM, during an interview with R #1, she pointed to the wall near her window and stated the velcro had been on the wall since she moved into the room approximately 2 months ago, she also stated that the wall behind her bed was scraped and the electrical outlet behind her bed did not have a cover on it. B. On 05/29/25 at 12:53 AM, an observation of R #1's room revealed the wall near her window had 4 pieces of velcro on it, the wall behind her bed had several deep scratches and missing paint and the electric outlet behind her bed where R #1 had her cell phone charger plugged in did not have an outlet cover on it.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Recite from 08/15/24 Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #16) of 6 (R #1, R #2, R #3, R #16, R #25, and R #26) residents reviewed for comprehensive care plans (plan that has measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #16's admission record, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Unsteadiness on feet. b. Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (a break in the neck of the long bone in the leg with normal healing). c. Unspecified fall. d. Other abnormalities of gait and mobility (an unusual walking pattern). e. Need for assistance with personal…

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 interview, the facility failed to meet professional standards of practice for 2 (R #16 and R #25) of 3 (R #1, R #16 and R #25) residents reviewed for neglect, when staff failed to: 1. Enter an order for urinalysis (a test of your urine. It is often done to check for a urinary tract infection, kidney problems, or diabetes) and urine culture (a test healthcare providers use to check for a urinary tract infection (UTI) by seeing if bacteria or fungi can grow from a sample of your pee. A urine culture test can also identify bacteria or yeast causing a UTI and which drugs work best to treat the infection) for R #16. 2. Collect urine for urinalysis and urine culture for R #16. 3. Administer R #25's blood pressure medication and insulin as ordered by the physician. These deficient practices could likely lead to the resident having worsening of their medical conditions, adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 1 (R #16) of 3 (R #16, R #25, and R #26) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #16's medical record, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 was discharged from the facility on 02/08/25. 3. R #16 had the following diagnoses: a. Unsteadiness on feet. b. Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (a break in the neck of the long bone in the leg with normal healing). c. Unspecified fall. d. Other abnormalities of gait and mobility (an unusual walking pattern). e. Need for assistance with personal care. B. Record review of R #16's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #16) of 1 (R #1, R #16, and R #25) residents reviewed for neglect. This deficient practice has the potential to negatively impact on the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. Record review of R #16's admission record, no date, revealed R #16 was admitted to the facility on [DATE]. B. Record review of R #16's progress note dated 02/07/25 revealed staff documented R #16 had burning during urination. C. Record review of R #16's On-Call physician note dated 02/07/25 revealed the provider ordered a urinalysis and urine culture due to dysuria (pain during urination). D. Record review of R #16's entire medical record, no date, revealed the following: 1. Staff did not document that the provider was notified about R #16 having burning during urination. 2. Staff did not enter any orders that were received when 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 document review, interviews, and facility policy review, the facility failed to ensure Registered Nurse (RN) coverage was provided eight hours a day seven days a week. The failure created the potential for 48 residents, residing in the facility, not to receive appropriate care and oversight. Findings include: Review of the Fiscal Year Quarter 2 Payroll Based Journal (PBJ) of the Certification and Survey Provider Enhanced Reports (CASPER), submitted by the facility, identified no RN coverage on the following dates: 01/21/24, 02/17/24, 02/18/24, and 03/16/24. On 08/15/24 at 9:06 AM, the Infection Preventionist (IP), responsible for staffing, confirmed that there was no RN coverage, on 02/17/24 and 02/18/24. The IP provided Timecard Report to show RN coverage was provided on 01/21/24 and 03/16/24. On 08/15/24 at 1:02 PM, the Business Office Manager (BOM) confirmed that he submits the PBJ reports and that there was no RN coverage on 02/17/24 and 02/18/24. The resident census on 02/17/24 and 02/18/24 was 48 per the BOM records. On 08/15/24 at 12:43 PM, the Director of Nurses…

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

Based on observation, interviews, and facility policy review, the facility failed to ensure a clean, environment for two of four hallways (hall one and hall leading to the dining room) and one resident (Resident (R) 31) room in the sample of 18 by heavily using disinfectant sprays. Findings include: 1. During the initial tour of the facility made on 08/12/24 at 10:15 AM, a strong smell of urine at the entrance to the 100 unit near the nurse's station. The facility was observed at this time to have carpet in the building in the day area, nurses station and 100/200 units. During an observation made on 08/12/24 at 3:00 PM, Housekeeper 2 (HSG2) was observed walking up and down the 100-hall spraying Lysol in the hallway and into the entrance of the residents' rooms. HSG2 was observed spraying the can of Lysol up into the air, and down onto the carpet from one end of the 100-hallway spraying from left to right. At this time, there were no residents observed in the hallway or sitting in the entrance of their rooms and the smell of Lysol was very strong and pungent. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, review of facility policies and Centers for Disease Control and Prevention guidance, the facility failed 1. to ensure that staff wore appropriate Personal Protective Equipment (PPE) for three of twelve residents (Resident (R) 31, 200, and 41) reviewed for enhanced barrier precautions (EBP) when providing care, 2. to clean and disinfect patient equipment after use for one of eight residents (R15) reviewed for infection control 3. To follow hand hygiene practices during medication pass for one of five residents (R15) reviewed for medication administration. These failures could promote the spread of multi drug resistant organisms (MDROs) throughout the facility. Findings include: 1. Review of R31's undated admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 06/06/22. The admission Record revealed a diagnosis of chronic obstructive pulmonary disease. Review of R31's annual Minimum Data Set (MDS) with an Assessment…

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 facility policy review, the facility failed to provide care for one of 18 sample residents (Resident (R) 100) as requested which left R100 feeling undignified and upset. R100 requested a shower prior to a doctor's appointment which was not provided. Findings include: Review of R100's Admission document located under the Profile tab in the electronic medical record (EMR) revealed R100 was admitted on [DATE] with diagnosis that included acute and chronic respiratory failure with hypoxia. Review of the Progress Notes, located under the Progress Note tab in the EMR from 07/30/24 through 08/13/24 that R100 was alert and oriented to person, place, time, and situation. Review of the Care Plan, located in the EMR under the RAI tab, dated 08/13/24, noted R100 requires extensive assistance with bathing. During an interview on 08/14/24 at 9:20 AM, R100 stated, I didn't get a shower last night (Tuesday) or this morning (Wednesday) at 6:30 AM. I was told they only had one CNA (certified…

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, record review, interviews, and facility policy review, the facility failed to assess one of one (Resident (R)3) resident for self-administration of medication in the sample of 18 residents. This had the potential to affect the residents' medication safety at the facility. Findings include: Review of R3's undated admission Record in the Profile tab of the electronic medical record (EMR) revealed most recent admission date of 06/15/23 and initial admission date of 11/09/21. The admission Record revealed a diagnosis of myocardial infarction. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/24, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was cognitively intact. During an observation and interview on 08/12/24 at 8:12 AM, two white tablets in a medicine cup on top of R3's bedside table. R3 stated, Those are Tums. They bring them when they bring my morning medication, and I think I'm supposed to take them. Sometimes I chew them and get rid 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 observations, record review, interviews, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately code the Minimum Data Set (MDS) for two of two residents (Residents (R) 10 and R34) receiving hospice services and one of four residents (R17) receiving oxygen therapy of 18 sampled residents. By not ensuring the accuracy of the MDS these failures could potentially place the residents at risk for unmet care needs not being addressed. Findings include: Review of the MDS-3.0 RAI Manual-v1.17.1, October 2019, under Section J1400 Prognosis: indicated, Definition: Condition of chronic disease that may result in a life expectancy of less than 6 months; In the physician's judgement, the resident has a diagnosis or combination of clinical conditions that have advanced or will continue to advance to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgement should be sustained by a physician note .Steps for Assessment: 1. Review the medical record for…

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

Based on record review, interviews, and facility policy review, the facility failed to develop a person-centered comprehensive care plan with measurable goals, specific objectives, and interventions for one of two residents (Residents (R)10) receiving hospice services of 18 sampled residents. By not developing a person-centered care plan the resident may not be receiving the appropriate interventions to achieve the highest practicable well-being. Findings include: Review of the facility's policy titled, Care Plan-R/S, LTC, Therapy & Rehab, revised 11/01/23, indicated Purpose: To develop a comprehensive care plan using an interdisciplinary team approach .Definitions: Comprehensive Care Plan-includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Person-centered care-a focus on the resident as the locus of control and supporting the resident in making his or her own choices and having control over their daily life. The policy further indicated, Each resident will have…

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, interviews, and facility policy review, the facility failed to ensure oxygen (O2) concentrators had dust free filters, and were free of a buildup of heavy lint and dirt on the inlet where the air came into the machine for two of four residents (Residents (R) 21 and R25) receiving oxygen therapy out of a sample of 18 sampled residents. This deficient practice had the potential to allow an increased chance of infection and unnecessary respiratory treatment. Findings include: Review of the facility's policy titled Oxygen Administration, Safety, Mask Types-Rehab/Skilled, LTC, Therapy & Rehab revised 07/08/24 indicated, Purpose- To administer and store oxygen in a safe manner, to keep oxygen equipment clean and maintained in a good condition .,All oxygen therapy equipment will be clean, safe, and functional at all times .Document cleaning of concentrator and filters where appropriate . 1. During an observation on 08/12/24 at 11:44 AM, on 08/13/24 at 8:58 AM, and on 08/13/24 at 12:30 PM, R21's oxygen concentrator filter located on the right bottom…

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, interviews, and policy review, the facility failed to provide documentation of behavior monitoring for the continued use of psychoactive medications for two of five residents (Resident (R) 7 and R19) reviewed for unnecessary medications. Failure to provide quantitative data regarding target behavior reduction/management has the potential to affect the resident receiving the lowest dose possible of a psychoactive medication. Findings include: 1. Review of R7's undated admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 06/11/24. The admission Record revealed a diagnosis of pneumonia, unspecified organism. Review of R7's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 was cognitively intact. Review of R7's August 2024 Medication Administration Record (MAR) under the report tab of the EMR revealed the following current psychotropic medication 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.

Based on observation and interview, the facility failed to ensure food was stored properly for all 50 residents who eat food prepared in the kitchen (residents were identified by the Census list provided by the Administrator on 10/01/23), when they failed to label and date food items in the pantry and in the refrigerator. These deficient practices could lead to residents becoming sick from foodborne illnesses. The findings are: A. On 10/02/23 at 11:28 AM, during an observation of the Kitchen pantry revealed: 1. A package of linguini noodles opened with no date, 2. A package of spiral noodles opened with no date, 3. An open bag of tortillas chips no date, 5. A package of bologna no label and no date, 6. A parmesan cheese no date, 7. A block of yellow cheese (unidentified) with no label and no date. B. On 10/02/23 at 11:37 AM, during an observation, the kitchen's refrigerator revealed a bag of shredded lettuce with no label and no date with some pieces looking brown in color. C. On 10/01/23 at 11:40 AM, during an interview, the Dietary Manager confirmed the food items are expected 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 interview and observation, the facility failed to post notice of the availability of the most recent state survey in areas of the facility that were prominent and accessible to residents and the public. This could affect all 50 residents in the facility (residents were identified by the Census Report provided by the Administrator on 10/01/23). If residents are unable to locate the latest survey conducted by State Surveyors, then residents, representatives, and visitors are likely unable to know how the facility is doing and make decisions accordingly. The findings are: A. On 10/05/23 at 10:27 AM, during the Resident Council meeting, R #15, R #18, R #23, R #26, R #37, R #38, R #49, R #50, and R #110 revealed: 1. Residents were not aware that they had access to the most recent state survey results. 2. The residents did not know where the latest state survey results were located. B. On 10/05/23 at 11:45 AM, an observation revealed a survey binder in a hanging wall file not marked and behind a laminated paper. C. On 10/10/23 at 1:52 PM, during an interview with Medical Records,…

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, the facility failed to provide a comfortable and homelike environment for the 28 residents on the 100 Unit (Resident were identified by the Census list provided by the DON on 10/01/23), when they failed to keep the 100 unit free from institutional odors. This failed deficient practice could likely lead to an unsanitary and uncomfortable environment. The findings are: A. On 10/01/23 at 2:36 PM, during an observation, the 100 hall contained a strong odor of urine between room [ROOM NUMBER] and room [ROOM NUMBER]. B. On 10/02/23 at 10:40 AM, during an a family interview, the relative (R #19's) revealed the 100 hall smells of urine when she goes to visit. C. On 10/02/23 at 11:26 AM, during an observation, the 100 hall contained a strong odor of urine between room [ROOM NUMBER] and room [ROOM NUMBER]. D. On 10/02/23 at 11:48 AM, during an interview with R #32, she stated the 100 hallway smells of urine. D. On 10/03/23 at 12:34 PM, during an observation, the 100 hall contained 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 record review and interview, the facility failed to ensure a comprehensive assessment (complete assessment that included not only the traditional care of the resident, but also the prevention and early detection of disease and rehabilitation) was completed and accurate for 3 (R #31, R #46 and R #48) of 6 (R #31, R #46, R #47, R #48, R #49, and R #107) residents reviewed for activities. When they failed to: 1. Complete MDS Section F, Preferences for Customary and Routine activities, for R #31 and R #46; 2. Complete the Interview for Daily Preferences on the MDS for R #48. This deficient practice could likely result in residents' preferences and needs not being met. The findings are: R #31 A. Record review of R #31's Annual MDS, dated [DATE], revealed staff did not complete the following areas of Section F, Preferences for Customary and Routine activities: 1. F0300 Should interview for daily activities preferences be conducted? 2. F0400 Interview for Daily Preferences, Show resident the response options…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the MDS assessments were accurate for 3 (R #1, R #30, and R #31) of 4 (R #1, R #30, R #31, and R #48) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are: R #1 A. Record review of R #1's Care Plan, dated 03/23/23, revealed: [name of R #1] is at risk for falls R/T (related to) Confusion, Gait (walking)/balance problems, Incontinence (involuntary urination). 03/24/23 found on floor no apparent injuries. B. Record review of R #1's Quarterly MDS, dated [DATE], revealed Question J1800 Has the resident had any falls since admission/entry or reentry, or the prior assessment was answered 0-No. R #30 C. Record review of R #30's Physician's Orders revealed: Order Date 08/07/23 - Hospice referral to evaluate and treat for change in condition. D. Record review of R #30's significant change of condition MDS, completed on 09/21/23, revealed: Section O:…

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 interview, the facility failed to create a Baseline Care Plan (Plan that includes the instructions needed to provide effective and person-centered care upon admission) within 48 hours of admission for 1 (R #156) of 3 (R #107, R #109, and R #156) residents sampled for Baseline Care Plans. When they failed to: 1) Develop R #156's baseline care plan within 48 hours after admission, 2) Create a plan of care for R #156's pressure ulcers. This deficient practice could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (An event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #156's admission Record, (no date) revealed R #156 was admitted on [DATE]. B. Record review of R #156's admission MDS, dated [DATE], Section I Active Diagnoses revealed: 1. Question I8000E,…

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 interview, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #46 and R #107) of 7 (R #1, R #14, R #15, R #31, R #46, R #49 and R #107) residents reviewed for Comprehensive Care Plans. Failure to develop a comprehensive person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being. The findings are: R #46 A. Record review of R #46's admission Minimum Data Set (MDS: resident assessment, completed by staff), dated 12/22/22, revealed: 1. Section L Oral/Dental Status was answered: D. obvious or likely cavity or broken natural teeth. 2. Section V Care Area Assessment (CAA; triggered areas indicating a care plan is necessary) Summary revealed: V0200 15. Dental care was marked for care area triggered and care planning decision. B. Record review of R #46's Care Plan, dated 12/23/22, revealed the careplan did not include oral/dental care. C. On 10/11/23 at 2:09 PM, during an interview, the DON confirmed…

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 interview, the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to support their physical, mental, and psychosocial well-being for 1 (R #48) of 5 (R #31, R #46, R #47, R #48 and R #49) residents reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression and could likely experience a decline in independence. The findings are: R #48 G. On 10/02/23 at 2:57 PM, during an interview, R #48 revealed he was not offered activities for vision impaired. He stated the staff are not trained to help him appropriately, because he is blind. H. Record review of the Activities calendar, for the month of October 2023, revealed it did not contain activities for the vision impaired, and nothing on the activities was altered for visually impaired. I. Record review of R #48's care plan, dated 05/21/23,…

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

Based on observation and interview, the facility failed to keep residents free from accidents for all 41 residents in the facility (residents were identified by the Census Report provided by the Administrator on 10/01/23), when they failed to secure a treatment cart. This deficient practice could likely result in residents obtaining medical equipment that could be harmful to them resulting in injury. The findings are: A. On 10/01/23 at 9:42 AM, during an observation, the nurse's station area revealed a treatment cart unlocked. No staff were present. B. On 10/01/23 at 9:43 AM, during an interview, CNA #11 confirmed that the treatment cart was unlocked. C. On 10/02/23 at 9:24 AM, during an observation, the nurse's station area revealed a treatment cart unlocked, and no staff were present. D. On 10/02/23 at 9:25 AM, during an interview, CNA #12 confirmed the treatment cart was unlocked and said it is supposed to be locked. E. On 10/05/23 at 1:29 PM, during an interview, the DON confirmed that treatment carts and medication carts should be locked when not in use.

Based on interview and record review, the facility failed to ensure appropriate treatment and services for Foley catheter tubing and collecting bag (soft plastic or rubber tube that is inserted into the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #47) of 1 (R #47) resident sampled for urinary catheter, when they failed to complete Foley catheter care and flushes as ordered. This deficient practice could likely result in residents getting infections. The findings are: A. On 10/01/23 at 12:25 PM, during an interview with R #47, she stated: 1. Staff do not always drain her catheter bag at night, and it leaked due to over filling. 2. She had a lot of sediment in her urine which clogged up the catheter if it is not flushed correctly twice daily. B. On 10/02/23 at 10:45 AM, during an interview with R #47, she stated: 1. Staff do not always backflush (define for the public is this different from the flush stated above) the catheter. 2. When flushed correctly, she is able to keep the Foley catheter for 30 days. C. Record review of R #47's active 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 record review and interview, the facility failed to ensure staff acted upon pharmacy recommendations when they failed to: 1. Have the physician review and sign off on the pharmacy recommendations for residents reviewed by the consult pharmacist for medication regimen reviewed in July 2023. 2. Follow the pharmacist recommendation for maximum recommended dose for R #15's acetaminophen. This deficient practice could affect all 50 residents in the facility (residents were identified on the resident matrix provided by the Administrator on 10/01/23). This deficient practice could likely result in residents being at a higher risk of adverse (undesired harmful effect resulting from medication) side effects. The findings are: R #15 A. Record review of R #15's Order Summary report for active orders as of 10/05/23 revealed: Tylenol (brand name of acetaminophen), oral tablet, 325 mg (dosage of medication). (acetaminophen) Give 650 mg by mouth every 4 hours as needed for pain. No maximum dosage listed. B. Record…

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 interview, the facility failed to provide a drug regimen that was free from unnecessary medication for 1 (R #25) of 1 (R #25) residents reviewed for anticoagulants (a group of medications that decrease your blood's ability to clot) when they prescribed R #25 an anticoagulant for hypertension (when the pressure in your blood vessels is too high). This deficient practice could likely cause R #25 to receive medication he does not need or no longer needed. The findings are: A. Record review of R #25's Physicians Orders revealed Apixaban (anticoagulant) tablet, 2.5 mg, (milligram, a unit of measurement of mass in the metric system equal to a thousandth of a gram) related to essential hypertension, dated 09/13/22. B. On 10/04/23 at 1:57 PM, during an interview with the DON, she confirmed the order for Apixaban was prescribed for hypertension. The DON stated that Apixaban should not be prescribed for hypertension.

Based on observation and interview, the facility failed to properly store medications, when they failed to: 1. Dispose of loose tablets stored in the medication carts for the 300 unit. 2. Properly label open bottles of medications stored in the medication carts for the 100 and 300 units. 3. Ensure medication was not expired in the Pyxis (medication management software and medication dispensing machine). This could affect all 41 residents in the 100 unit and 300 unit of the facility (Residents were identified by the resident matrix provided by the Administrator on 10/01/23). These deficient practices could likely result in residents obtaining medications that are no longer effective or that are not prescribed to them resulting in adverse side effects. The findings are: 300 Unit Medication Cart A. On 10/05/23 at 10:01 AM, during an observation of the 300 unit medication cart revealed the following: 1. 1 open bottle acetaminophen, 500 mg, with no open date. 2. 1 open bottle Vitamin D, 25 mcg (microgram), with no open date. 3. 1 bottle melatonin (supplement given to regulate sleep), 5…

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

Based on interview and record review, the facility failed to notify the resident representative of resident change in condition which required a hospice consult for 1 (R #30) of 1 (R #30) residents reviewed for notification of change. This deficient practice could likely result in the resident representative being unable to provide advocacy and make medical decisions when needed. The findings are: A. On 10/02/23 at 12:44 am, during an interview with R #30's daughter, she stated staff did not notify her or her sister about R #30's change in condition or that the provider ordered a hospice referral for R #30. R #30's daughter stated she only found out about hospice when the hospice facility called her to have her sign paperwork. B. Record review of Nursing Progress Notes for R #30 revealed: 1. 08/07/23 at 8:39 PM, MD (medical doctor) notified of change in condition for resident . MD notified of the confusion and refusal of the medication. MD was also notified of visual signs of weight loss. MD requested for a hospice referral. Will cont. (continue) to follow up if needed. 2. The…

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

Based on interview and record review, the facility failed to complete a significant change (major decline or improvement in the patient's health status) MDS in a timely manner (within 14 days after the facility determines, or should have determined, there has been a significant change in the resident's physical or mental condition) for 1 (R #30) of 1 (R #30) residents sampled for hospice (care that focuses on alleviating symptoms of the terminally ill). This deficient practice could likely result in the resident not receiving the appropriate care and services they need. The findings are: A. Record review of R #30's Physician's Orders revealed: 1. On 08/07/22, a hospice referral was ordered for R #30. 2. On 08/21/23, R #30 was admitted to hospice. B. Record review of R #30's change of condition MDS assessment, dated 09/21/23, revealed R #30 had a significant change. The record did not contain documentation that R #30 started hospice service. C. On 10/04/23 at 11:13 AM, during an interview with the MDS coordinator, she confirmed staff should complete a significant change of condition…

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 interview, the facility failed to develop an effective discharge plan for 1 (R #54) of 1 (R #54) residents reviewed for discharge planning (the process of transitioning a resident from one level of care to the next). This deficient practice could likely result in complicated and/or unsafe transitions from the facility to the residents' post-discharge settings. The findings are: A. Record review of R #54's face sheet revealed: 1. admitted to the facility on [DATE], 2. Medical diagnoses: a. Gout, unspecified (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones.) b. Hypokalemia (a lower than normal potassium level in your bloodstream.) c. Hypocalcemia (a treatable condition that happens when the levels of calcium in your blood are too low.) d. Essential hypertension (high blood pressure that is multi-factorial and does not have one distinct cause.) e. Gastro-esophageal reflux (a digestive disease in which stomach acid or bile irritates…

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 interview, the facility failed to ensure a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) was completed for 1 (R #54) of 1 (R #54) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility or hospital not knowing what the current care needs and significant medical history are for the resident. The findings are: A. Record review of R #54's face sheet revealed: 1. admitted to the facility on [DATE], 2. Medical diagnoses: a. Gout, unspecified (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones.) b. Hypokalemia (a lower than normal potassium level in your bloodstream.) c. Hypocalcemia (a treatable condition that happens when the levels of calcium in your blood are too low.) d. Essential hypertension (high blood pressure that is multi-factorial and does not have one distinct cause.) e.…

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.