Schervier Nursing Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the re-certification and Complaint Investigation survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 1 resident reviewed for Personal Funds (Resident #19), out of total sample of 38 residents. The findings are: The facility Policy and Procedure on Resident's Right regarding Funds dated 05/2002, last revised 12/2019 documented that the facility will permit each resident the right to manage his/her personal financial affairs; will ensure that the resident/designee will have ability to view their active balance and have access to their funds. Resident #19 was admitted to the facility 07/11/2014, with diagnoses that included Hypertension, Hyperlipidemia, Arthritis,…

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

Based on record review and staff interviews during the recertification survey, the facility did not ensure that an appropriate surety bond was purchased, or otherwise assurance satisfactory to the Secretary was provided, to assure the security of all personal funds of residents deposited with the facility. Specifically, there is no surety bond in place to assure the residents fund against lost. This was evident for 434 residents who maintained personal funds accounts, current total balance of $356,043.48, (Three hundred fifty-six thousand, forty-three dollars, and forty-eight cents) The findings are: The facility Policy and Procedure on Resident's Right regarding Funds dated 05/2002, last revised 12/2019 documented that the facility will permit each resident the right to manage his/her personal financial affairs; will ensure that the resident/designee will have ability to view their active balance and have access to their funds. Resident Fund Trial Balance as of 10/03/2023 documented Total Account: 434; Current balance: $356,043.48, (Three hundred fifty-six thousand, forty-three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 10/2/2023 to 10/11/2023, the facility did not ensure that Advance Directives (AD) were implemented in a manner that was consistent with resident's wishes. This was evident for 1 (Resident #183) of 41 total sampled residents. Specifically, facility did not ensure Resident #183's AD that included specific instructions not to provide antibiotics or IV were followed. The findings are: The facility procedure and policy titled Advance Directives reviewed 3/22 documented residents and their designated representatives to formulate and express (in writing or verbally) advance directives for medical care. Advance directives can include but is not limited to a MOLST(Medical Orders for Life Sustaining Treatment), Health Care Proxy, Living Will or Durable Power of Attorney for Health Care Decision Making. Resident #183 was admitted to the facility with diagnosis of Alzheimer's Disease, Diabetes Mellitus and Anxiety Disorder.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 10/2/2023 to 10/11/2023, the facility did not ensure the resident's representative was notified of a significant change in resident's condition and a need to alter treatment. This was evident for 1 (Resident #183) of 41 total sampled residents. Specifically, Resident #183's designated representative was not notified of initiation of IV antibiotic therapy and fluids administered for resident who developed an infection. The findings are: The facility procedure and policy titled Notification of Changes in a Resident's Status revised 8/22 documented that all relevant team members, residents and designated representatives be appropriately informed of changes in resident's status. Resident #183 was admitted to the facility with diagnosis of Alzheimer's Disease, Diabetes Mellitus and Anxiety Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident had severely impaired cognition. 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, during the recertification survey, the facility did not ensure that a resident was free from physical restraints. Specifically, a resident had half upper side rail on the left side and half lower side rail on the right side up. This was evident for 1 of 1 resident reviewed for Physical Restraints (Resident #254). The findings are: Policy and Procedure titled Side Rail Use, last revised in August of 2022 stated as follows: It is the policy of Schervier Nursing Care Center that side rails will be used only when they are deemed to benefit the resident in increasing his/her mobility in bed, as an assistive device/enabler. Physical restraints are defined as any manual method of physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Resident #254 diagnosed with hypertension, anxiety and osteoarthritis. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Complaint (NY00319294) survey from 10/02/2023 to 10/11/2023, the facility did not ensure all allegations of abuse, including injuries of unknown origin were reported to the New York State Department of Health (NYSDOH) within two hours. This was evident for 2 (Resident #11 and #20) of 41 total sampled residents. The findings are: The facility's policy and procedure entitled Accident and Incident Reporting and Investigating, last reviewed 10/2023, states that the facility will ensure that all accidents or incidents are promptly reported. Following an occurrence, the nurse notified the Nurse Manager/Supervisor, who initiated an Accident/Incident Report. The Director of Nursing signs off on the Accident/Incident Report and calls in the event to the Department of Health as applicable. 1) Resident #11 had diagnoses of Epilepsy, Hemiplegia, and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #11 Based on record review and interviews conducted during the Recertification and Complaint (NY00319294) survey from 10/02/2023 to 10/11/2023, the facility did not ensure that all allegations of abuse, including injuries of unknown origin, were thoroughly investigated. This was evident for 2 (Resident #11 and #20) of 41 total sampled residents. Specifically, 1) there was no documented evidence an investigation was conducted when Resident #11 reported a fall to their designated representative and complained of headaches and tenderness to their forehead, and 2) there was no documented evidence an investigation was conducted for Resident #20 who had ecchymosis to their forehead. The findings are: The facility policy titled Abuse, Neglect, and Exploitation, Prevention, and Intervention dated 1/2020 documented all departments/all staff identifies and immediately reports all allegations, reports or witnesses' incidents of abuse, neglect, exploitation, or mistreatment. Reports including new bruising, injuries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the recertification survey from 10/2/23 to 10/11/23, the facility did not ensure Minimum Data Set (MDS) 3.0 assessment was completed in a timely manner. This was evident for 1 (Resident #504) of 12 residents reviewed for Resident Assessment. Specifically, the admission MDS assessment was not completed within 14 calendar days from the Assessment Reference (ARD) Date (Resident #504). The findings are: The facility policy and procedure titled MDS Assessment & Submission revised 8/23 documented that the federal and state required MDS assessments are set, completed accurately, and submitted timely for all residents. IDT collects, organizes, and evaluates relevant information concerning all residents' health and overall condition, completing the assigned portions of the MDS assessments within the required time frame. Resident #504 was admitted to the facility on [DATE]. The admission MDS assessment with ARD of 3/29/23 was completed late on 4/26/23. On 10/11/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during the Recertification/ Complaint survey (NY00307350 & NY003188668), the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, No CCP developed and implemented for resident's use of IV Antibiotic for chronic Urinary Tract infection (UTI). This was evident for 1 of the 5 complaint investigations (Resident #71). The findings are: The facility policy and Procedure titled Interdisciplinary Comprehensive Care Planning dated 11/2010, last revised 08/2020, documented: Interdisciplinary clinical team, upon completion of the comprehensive assessment, develops, at a minimum, care plans for the triggered care areas .In addition, reviews and updates the care plan as needed, after an occurrence, or any sig changes; implements a care plan for episodic conditions Resident #71 was admitted to the facility 12/16/2021,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview conducted during the Recertification survey from 10/2/23 through 10/11/23, the facility did not ensure that a resident Comprehensive Care Plan (CCP) was reviewed and/or revised after each assessment and as needed to reflect the resident's needs. This was evident for 2 out of 41 residents reviewed (Resident # 82 and #289). Specifically:1) CCP related to Activities for Resident #82 were not reviewed and revised quarterly, and 2) the Nutrition CCP for Resident #289 was not reviewed quarterly and after a significant weight loss. The Findings are: The facility's policy and procedure titled Interdisciplinary Comprehensive Care Planning, with the last reviewed date of 8/2020, documented that, at a minimum, every quarter after the scheduled comprehensive assessment, meets, evaluates, and revises the resident's care plan. In addition, it reviews and updates the care plan as needed after any significant change. 1.) Resident #82 was admitted with diagnoses that include…

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, observations, and staff interviews during the Recertification survey on 10/2/2023 to 10/11/2023, the facility did not ensure that a resident with limited range of motion (LROM) received appropriate treatment and needed services, and equipment to increase range of motion and/or to prevent further decrease in range of motion and contracture. This was evident for 1(Resident # 321) of 2 residents reviewed for Position, Mobility. Specifically, Resident #321 had changes in the right wrist with negative x-ray findings. The wrist issues continued and were not assessed by an Occupational Therapist (OT)/Physical Therapist (PT). The orthopedist recommended Occupational Therapy (OT)/Physical Therapy (PT), a right wrist brace, and Range of Motion (ROM) as tolerated. Resident #321 never received the OT/PT or right wrist brace as ordered. The findings are: The facility's policy titled Transcription of Medical Orders revised 9/20 documented that the Clinical Nurse Manager is responsible for reviewing all MD/Nurse Practitioner orders received for the day. Reviews 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 staff interviews and record review conducted during the Recertification Survey from 10/2/23 to 10/11/23, the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for a resident's needs as described in the plan of care. This was evident for 1 (Resident #242) of 10 residents reviewed for accidents out of 40 sampled residents. Specifically, Certified Nursing Aide (CNA) #6 was not competent in the usage of a scoot chair that was assigned to Resident #242. The findings are: The facility's policy titled 'Inservice Education', last revised 11/22, documented that the purpose is to maintain a high standard of resident care, and that will include subjects based on other topics deemed necessary for quality care. On 10/05/23@ 12:30 PM, the State Surveyor (SS) was sitting at the nursing station on Unit 2 South, when they heard CNA #6 say put up your legs, put up your legs. The SS then observed CNA #6 pulling Resident #242 backwards, in a scoot chair,…

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 and interview during the Recertification/Complaint survey (NY00307350 & NY003188668), the facility did not ensure that resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the resident. Specifically, resident's medication was not crushed prior to administration as per physician's order and the plan of care. This was evident for 1 of the 5 complaint investigations (Resident #71). The findings are: The facility Policy and Procedure for Medication Administration dated 09/2016, last revised 01/2022, documented: Orders automatically transferred to the EMAR/ETAR (electronic Medication/Treatment Administration Record); Prior to administering medication/treatment the nurse will verify orders by comparing the written medication order against the order entered into PCC (Point Click Care) On 10/03/23 at 01:04 PM, during the Medication Administration observation, LPN #1 was observed administering Senna tablets to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 10/2/2023 to 10/11/2023, the facility did not ensure that foods were served at an appetizing temperature during meal service. This was evident for 1 of 1 resident (Resident #37) reviewed for Food out of total 41 sampled residents. Specifically, hot food items served during lunch meal service were not maintained at palatable and appetizing temperatures. The findings are: The facility procedure and policy titled Food Safety dated 3/21 documented that all foods will be held at appropriate temperatures, greater than 135 degrees F for hot holding and less than 41 degrees F for cold food holding. Temperature for TCS foods will be recorded at time of service and monitored periodically during meal service periods. The lunch meal times for 2 South starts 11:30AM to 11:40AM, 2 North starts 11:40AM to 11:50AM, 3 South starts 11:50AM to 12:00PM and 3 North starts at 12:00PM to 12:10PM. Resident #37 was admitted to the…

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

Based on observations, interviews, and record review conducted during the recertification survey 10/02/23 - 10/11/23, the facility did not ensure that food was stored according to professional standards for food safety. This was evident for 1 of 8 unit pantries observed for the Kitchen task (Unit 3 North). Specifically, food items were stored in the pantry refrigerator without being labelled and dated. The findings are: The facility policy and procedure titled Unit Pantry Stock last revised in July 2019 stated as follows: All items opened must be labeled with date opened and use-by-date. Labels will be provided by the Dining Services Department. Items brought in by family members for resident use must be also labeled with date brought in, use-by date and resident name. On 10/02/23 at 10:10 AM, upon pantry inspection conducted on the Unit 3 North the surveyor observed (#1) 11 cupcakes stored in a large cardboard box in the pantry refrigerator, which was not labeled or dated, (#2) A metal tray with 2 plastic bags containing water and (#3), 3 open containers of juice which 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.

Based on observation, record review, and interviews during an abbreviated survey (Case # NY 00309085), the facility did not ensure that a resident receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident in 1 out of 5 residents sampled (Resident #1). Specifically, on 01/15/2023, at approximately 9:00 AM, Certified Nurse Assistant (CNA) #1 reported to Licensed Practical Nurse (LPN) #1, that Resident #1 had redness to the chest and the clothes in the chest area was wet. LPN #1 observed the redness on Resident #1's chest but did not notify the Registered Nurse Supervisor (RNS) or the Medical Doctor (MD). On 01/15/2023 at 7:00 PM, CNA #2 observed redness with a blister on Resident #1 's chest and reported to LPN #1. LPN #1 observed redness on Resident #1's chest and documented in the MD's notification book. On 01/16/2023 at 4:24 PM, LPN #1 informed RNS #1 of redness to Resident #1 chest area. On 01/16/2023 at 9:22 PM, a Physician's Progress Note documented that the MD…

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 record review conducted during an Abbreviated Survey (NY00320576), the facility failed to protect the resident's right to be free from physical abuse by nursing home staff. This was evident for one out of three residents (Resident #1) sampled for abuse. Specifically, on 07/21/23, an undated video clip provided by the Administrator, showed Licensed Practical Nurse (LPN) #1 roughly grabbed Resident #1's upper right arm. Resident #1 did not sustain any visible injuries. The findings are: The facility Policy and Procedure, Abuse, Neglect & Exploitation Prevention, and Intervention reviewed January 2020 states that Facility will treat each resident with respect, and full recognition of his or her dignity and individuality. The Facility is committed to prevention of abuse, neglect or exploitation and prompt investigation of allegations and instances of resident abuse, neglect and/or exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.…

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 staff interview during an abbreviated survey (NY00321535), the facility did not ensure that infection control practices were maintained. Specifically, on 08/25/2023 at 9:50AM, Certified Nursing Assistant (CNA) #3 entered a positive COVID-19 resident's (Resident #3) room without donning gloves and an isolation gown. CNA #3 exited the positive COVID-19 resident room, then entered a non-COVID-19 room afterward. Additionally, CNA #3 did not perform hand hygiene. The findings are: The facility policy and procedure Cohorting for COVID-19 residents dated 02/2023 documented nursing staff are trained and educated to render care to those residents who are testing negative for COVID-19 and then follow the facilities infection control protocol and removes personal protective equipment (PPE) and washes their hands, and then render care to the resident who tests positive for COVID-19. During an observation on 08/25/2023 at approximately 9:50AM CNA #3 was observed picking up food trays from a positive COVID-19 room without donning an isolation gown and gloves. CNA # 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews during the Recertification Survey, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag and tubing were left uncovered and exposed to public view. This was evident for 1 of 3 resident reviewed for Dignity out of a sample of 39 residents. (Resident #300) The finding is: The facility's policy titled Urinary Catheter Change/Care created in 2011, revised on 01/15/19, documented that nursing staff is to ensure that the urinary bag is not touching the floor, and the bag is covered for privacy. Resident #300 was admitted with diagnoses that included Heart Failure, Neurogenic Bladder, and Hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognitive status was severely impaired, and the resident required extensive assistance with transfer, toilet use, and personal hygiene. The Physician's order dated 04/22/21 documented the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that residents with limited Range of Motion (ROM) were provided services and treatment to increase ROM and to prevent further decrease in ROM, including the provision of equipment. Specifically, a resident observed with limited range of motion on the right hand was not being provided with interventions to help maintain the joint integrity and prevent a worsening contracture. This was evident for 1 of 4 residents reviewed for Position/Mobility out of a sample of 39 residents. (Resident #151) The findings are: The facility policy and procedure titled Rehab/Assistive Devices dated 12/2010, last reviewed 11/2020, documented that the nurse will assess resident to see if there is a physical change in status that would warrant a rehab referral; get MD order for rehab evaluation. The PT/OT Therapist evaluates resident as per MD order; will provide Rehab/Assistive Devices if indicated;…

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 reviews, and staff interviews, the facility did not ensure that a resident maintained acceptable parameters of nutritional status. Specifically, the facility did not effectively monitor a resident who was at risk for weight loss and weight fluctuations and who sustained a significant weight loss. This was evident for 1 of 4 residents reviewed for Nutrition out of a sample of 39 residents. (Resident # 44) The finding is: The facility policy titled Weight Monitoring Program created on 11/2011, revised on 01/16/20 documented the following: The facility will identify significant, undesirable weight gain\loss and initiate a plan of care to address undesirable weight changes. The policy also documented that the Dietician would review all completed weights and arranges for re-weights within 48 hours if weight change is 5 pounds or more (or 3 pounds for residents < 100 pounds). The policy further documented that the Dietician reviews all completed weights and identifies any resident 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.