Elderwood At Cheektowaga

Based on record review and interview conducted during the survey, the facility failed to ensure Certified Nurse Aide performance reviews were completed once every 12 months per year for three (3) (Certified Nurse Aides #3, #9, #10) of five (5) reviewed. Specifically, there was no evidence Certified Nurse Aides #3, #9, #10, who had worked for the facility more than 12 months had performance reviews completed at least once every 12 months.The findings include:The policy and procedure titled In-Service Attendance Program dated 07/19/2023 documented all staff/workforce will be expected to attend mandatory and non-mandatory in-service programs. Administrators were responsible for ensuring all employees and contractors attend annual mandatory training. At the time of the annual job performance review of a staff member, the evaluating manager will take into consideration as to whether or not the staff member was in compliance with mandatory in-service attendance.Review of the In-Service Education Record Binder on 04/23/2026 at 1:00 PM revealed Certified Nurse Aide #3's last annual…

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

Based on observation, interview and record review conducted during the survey, the facility failed to maintain drugs and biologicals labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration date when applicable for one (1) of four (4) resident units reviewed for medication storage. Specifically, the facility failed to ensure the safe and secure storage of medications. The Unit four (4) South medication cart was not locked and under the direct view of authorized staff. The computer system on the cart had visible patient health information displayed in an area where residents, staff, and visitors had access. Resident #75 was involved. Additionally, the Unit four (4) medication refrigerator had one (1) opened multidose vial of Tuberculin Purified Protein Derivative (Mantoux) solution that was opened on 12/13/2025 and not discarded after twenty-eight days and one (1) opened bottle of Humalog (insulin lispro injection) medication without an opened date that was not discarded after twenty-eight…

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 the survey, the facility failed to ensure each resident received food that accommodated resident allergies, intolerances, and preferences for one (1) (Resident #164) of one (1) resident reviewed. Specifically, Resident #164 received pork against their religious food preference. The findings include: The facility policy titled Accommodating Cultural Food Preferences revised 05/24/2019 documented the cultural or religious food preferences of residents will be accommodated whenever necessary by the dining services staff, and cultural preferences will be respected and accommodated upon request. The facility policy Assessment of Needs - Dietary revised 07/22/2025, documented each resident will have an assessment of dietary and nutritional needs completed by a Registered Dietitian or Diet Technician. The assessment was done for the following reasons which included but not limited to: record and follow the diet requirements specified by the Attending Physician; to fulfill immediately the personal preferences 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 observations, interviews, and record review conducted during the survey, the facility failed to ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) (Resident #8 and Resident #70) of three (3) residents reviewed for Infection Prevention and Control. Specifically, staff failed to maintain enhanced barrier precautions (interventions designed to reduced transmission of multi-drug-resistant organisms (MDRO) including gown and glove use during high contact resident care activities) and wear the appropriate personal protective equipment while providing hands on care to Resident #8 who had pressure ulcers and an indwelling catheter (tube inserted into the bladder to drain urine) and when providing wound care to Resident #70 who had pressure ulcers.The findings include:The facility policy titled Transmission Based…

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

Based on interviews and record review conducted during the survey completed the facility failed to ensure certified nurse aides were provided the required hours of training and/or annual in-services to ensure safe delivery of care for two (2) (Certified Nurse Aides #2 and #9) of five (5) reviewed. Specifically, Certified Nurse Aides #2 and #9 did not receive 12 hours of nurse aide in-services and education in 2025.The findings include:The policy and procedure titled In-Service Attendance Program dated 07/19/2023 documented administrators were responsible for ensuring all employees and contractors attend annual mandatory training. Announcements for the availability of online and instructor-led training were sent via email, electronic medical record and employee bulletin boards. At the time of the annual job performance review of a staff member, the evaluating manager will take into consideration as to whether or not the staff member was in compliance with mandatory in-service attendance.Review of the Job Description titled Educator dated 07/2023 documented the Educator was…

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

Based on interview and record review the facility did not ensure infection control practices were maintained to include when the COVID -19 vaccine is available to the facility, each resident is offered the COVID -19 vaccine unless immunization is medically contraindicated or the resident has already been immunized. Before offering COVID-19 vaccine, each resident or the resident representative received education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine; the resident has the opportunity to accept or refuse the COVID-19 vaccine and change their decision and that the resident's medical record includes documentation that indicated if a resident did not receive the COVID-19 vaccine due to medical contraindications or refusal for one (1) of three (3) residents reviewed for infection control. Specifically, the medical record did not have evidence of declination for the refusal of the COVID-19 vaccination for Resident #3 and there was no evidence that education regarding the risks and benefits about the COVID-19 vaccination was provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the survey, the facility did not ensure that a resident has the right to refuse treatment for two (2) (Resident #1 and #2) of three (3) residents reviewed for immunizations. Specifically, Resident #1 and Resident #2's Representatives did not give consent to administer the COVID-19 and influenza vaccines, and the residents received them. The findings are:The policy titled COVID-19 Vaccine Policy dated 07/25/2025, documented vaccination fact sheets will be made available to residents and resident representatives prior to administration. Informed consent either written or verbal will be obtained from all individuals being vaccinated. The vaccination is voluntary for all residents. Facility staff will monitor for potential side effects, in accordance with CDC (Centers for Disease Control and Prevention).The policy titled Influenza Immunization (Residents) Policy dated 09/24/2024, documented the facility will notify all residents and/or responsible parties…

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 conducted during the survey, the facility did not maintain accurate medical record documentation for three (3) (Resident's #1, #2, and #3) of three (3) residents reviewed. Specifically, Residents #1, #2 and #3 were administered vaccinations by an outside pharmacist that were documented as being administered by facility nurses. The findings are:The policy titled Influenza Immunization (Residents) Policy revised 09/24/2024, documented residents will receive immunizations from a licensed nurse of this facility according to the physician's order. The administration of the vaccine will be documented on the Medication Administration Record. For residents that receive influenza vaccines from other than facility staff, historical documentation will be completed on the master log in the medical record utilizing the immunization module in the electronic medical record.The policy titled Medication Administration Methods revised 01/25/2024, documented the Medication Administration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review completed during a Complaint (2590368) investigation completed on 11/05/2025 the facility did not ensure that residents who had an indwelling Foley catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (1) (Resident #3) of three (3) residents reviewed for foley catheters. Specifically, Resident #3 had a history of urinary tract infections and staff did not keep the urine collection bag below the level of Resident #3's bladder while the resident was sitting in their wheel chair, was not wearing a urine collection leg bag (a drainage bag that is attached to the thigh) as care planned, and there was no medical provider orders for the indwelling catheter and/or care of it. Additionally, Resident #3's comprehensive care plan was not updated to accurately reflect their urinary status. The finding is: The policy titled Catheter, Daily Care (Indwelling) dated 11/23/2022 documented residents 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.

Based on observation, interview, and record review conducted during the Abbreviated Survey (Complaint #NY00376392) the facility did not ensure the resident's right to be free from verbal/mental abuse for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Certified Nurse Aide #1 was witnessed yelling at Resident #1. The finding is: The policy and procedure titled Abuse Prevention, Identification, Investigation, Protection and Reporting revised 4/30/24 documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility. The undated New York State Department of Health document titled Your Rights as a Nursing Home Resident in New York State documented as a resident in this facility you have the right to be free from physical, sexual, mental, and verbal abuse, corporal punishment, financial exploitation, and involuntary seclusion including physical and chemical restraints. Resident #1 had diagnoses including congestive heart failure, hypertension, and diabetes mellitus. The Minimum Data Set (a resident 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.

Based on interview and record review conducted during the Standard survey completed on 6/18/24, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and Director of Nursing (DON) for one (Resident #25) of five residents reviewed for drug regimen reviews. Specifically, the Consultant Pharmacist did not identify, or report medications prescribed and administered (antibiotic) for an excessive duration and did not identify and report inadequate indications for the continued use of that antibiotic. The finding is: The policy and procedure titled Medication Regiment Review by Pharmacy Consultant dated 12/2021 documented the pharmacy consultant will assess the medication regimen and review the medical chart of all residents monthly. The pharmacy consultant will review the medication regimen for appropriateness and rationality to determine if the medication therapy is optimally effective and has the least possible risk of adverse effects and identify irregularities. Irregularities include but are not limited 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 record review and interviews conducted during the Standard survey completed on 6/18/24, the facility did not ensure that the facility's infection and control program included antibiotic use protocols and a system to monitor antibiotic use for one (Resident #25) of one resident reviewed. Specifically, Resident #25 was receiving an antibiotic since 11/22/20. The use of the antibiotic was not monitored and tracked by the Infection Preventionist (IP)/Antibiotic Stewardship Program. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Program dated 1/2018, documented that the antibiotic stewardship program will provide a framework to ensure that antimicrobials are used appropriately and prudently within the facility. The framework would be overseen by the Infection Prevention and Control Committee. The Consultant Pharmacist will be aware of established guidelines and verify appropriate doses of antimicrobial therapy upon review of the medical chart. Tracking of antibiotic usage will occur by the Infection Preventionist/designee and will be reported to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a Standard survey completed [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with residents' wishes for one (Resident #8) of one resident reviewed for advanced directives. Specifically, Resident #8's Medical Orders for Life-Sustaining Treatment (MOLST) form and was not reviewed and renewed since [DATE]. The finding is: The policy and procedure titled Advanced Directives Surrogates and MOLST (Medical Orders for Life-Sustaining Treatment)-NY (New York) dated [DATE] documented Medical Orders for Life Sustaining Treatment (MOLST) works in alignment with known directives to assure that resident preferences are known and available across all continuum settings at the point of care, to guide 'right now' and 'from this time forward' treatment decisions. Do Not Resuscitate orders on Medical Orders for Life Sustaining Treatment (MOLST) will be reviewed and renewed no less than…

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 conducted during a Complaint investigation (#NY00330303) during the Standard survey completed on 6/18/24, the facility did not ensure the residents representative was notified of the need to alter treatment or to commence a new form of treatment and when there was a change in room assignment for one (Resident #152) of two residents reviewed. Specifically, the resident and resident's responsible party were not notified of a room change on 11/30/23. Additionally, when Resident #152 tested positive for COVID-19 on 12/17/23, there was no evidence their responsible party was notified. The finding is: Review of the policy and procedure titled Notification of Resident Changes dated 5/31/18 documented the facility will immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an interested family member when there is a need to alter treatment, commence a new form of treatment or a change in room or roommate assignment. Resident #152 had diagnoses which included hypertension,…

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

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00340373) during a Standard survey completed 6/18/24, the facility did not ensure residents have the right to personal privacy for one (Resident #41) of one resident reviewed. Specifically, staff did not provide privacy during personal care. The finding is: The policy and procedure dated 6/6/22 documented that each staff member will be personally responsible for ensuring that the rights of each resident are respected and not violated. Staff shall ensure that all residents are afforded their right to privacy in treatment and care for personal needs. The policy and procedure dated 8/1/2019 documented each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff must focus on assisting the resident in maintaining and enhancing their self-esteem and self-worth. Resident #41 had diagnoses which included congestive heart failure, ischemic cardiomyopathy (disease of the heart muscle), and osteoarthritis (degenerative joint…

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

Based on observation, interview, and record review conducted during the Standard survey completed on 6/18/24, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for one (Unit 4) of two medication storage rooms observed. Specifically, the Unit 4 medication storage room refrigerator had three opened, undated and one opened, outdated multi-dose vials of Tubersol solution (medication injected just under the skin to test for tuberculosis). Additionally, the Unit 4 medication storage room cabinet had issues with expired over the counter medications. The finding is: The policy and procedure titled Medication Rooms on Nursing Units dated 1/18/2024 documented medication rooms on the nursing units of the facility will be the areas where medications for residents are stored. The policy documented authorized persons are allowed in the room for the purposes outlined: Licensed Nurses (Licensed Practical Nurse, Registered Nurse) for administration 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 record review and interview conducted during a Complaint investigation (#NY00336714) during the Standard survey completed on 6/18/24, the facility did not obtain or provide radiology services to meet the needs of its residents for one (Resident #150) of one resident reviewed. Specifically, Resident #150 was ordered to have a lumbar (section of the spine) x-ray completed on 2/28/24 but did not have the x-ray completed until 3/4/24. Additionally, the order for x-rays obtained on 2/28/24 was not entered into Resident #150's electronic medical record. The finding is: The policy and procedure titled Electronic Physician Orders (Create, Confirm, Processing Orders) dated 7/23/2018 documented the licensed nurse who has obtained the order from the Medical Doctor, Physician Assistant or Nurse Practitioner transcribing the medical order into the electronic medical record will ensure the correct date, time, ordering prescriber, medication name, order category, communication method, route of administration, frequency, schedule, indications for use or diagnosis and source details 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 interview and record review conducted during a Complaint Investigation (#NY00328763) completed 2/8/24, the facility did not ensure that all alleged violations of abuse, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse, to the facility's Administrator and the State Survey Agency for one (Resident #1) of three resident reviewed. Specifically, Resident #1 reported an allegation of abuse/mistreatment to facility staff on 11/24/23 and it was not reported in the required timeframe to the Administrator and the New York State Department of Health. The finding is: The facility policy and procedure titled Facility Incident Reporting to DOH-NYS, modified on 9/20/23, documented the facility will be responsible for reporting allegations or occurrences to the New York Department of Heath that involve physical abuse or mental/verbal abuse. The policy and procedure documented that the facility Administrator or designee will report all alleged violations to state agencies immediately, but no later…

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 conducted during a Complaint investigation (Complaint #NY00328763) completed on 2/8/24, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment were thoroughly investigated for one (Resident #1) of three residents reviewed. Specifically, there was no evidence that Resident #1's allegation of abuse/mistreatment on 11/24/23 was thoroughly investigated. The finding is: The facility policy and procedure titled Abuse Prevention, Identification, Investigation, Protection and Reporting, modified 6/19/23, documented upon identification of an observed act or outcomes of abuse and mistreatment or expressions of fear that could be an indication of abuse and mistreatment, all staff were required to report the observation immediately to their direct supervisor, the Director of Nursing, or the Administrator so an investigation could begin. The policy documented that the facility Administrator, Director of Nursing, or designee would be responsible for the investigation and that all allegations of abuse, mistreatment or neglect…

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

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00322117) started completed 11/21/23, the facility did not ensure that services were provided to meet professional standards of quality care for one (Resident #1) of three residents reviewed. Specifically, medications were left unattended on Resident #1 bedside table and were not verified that they were taken as ordered. The finding is: The facility policy and procedure (P&P) titled Medications Administration Methods last modified 7/12/2022 documented a medication must never be left at bedside or be out of sight of the nurse administering the medication. The nurse must watch each resident take the medication, and ensure the medication is swallowed, unless the resident has an order for self-administration of medications. Medication administration is recorded on the Medication Administration Record (MAR). 1. Resident #1 had diagnoses that included schizophrenia, bipolar disorder, and heart failure. The Minimum Data Set (MDS-a resident assessment tool) dated 10/13/23 documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed 9/27/22 through 10/3/22, the facility did not ensure that a resident, with an indwelling catheter (Foley - tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for two (Residents #106 and 120) of three residents reviewed for urinary catheters. Specifically, staff improperly handled the urinary catheter tubing and urinary collection bag while resident displayed symptoms of a UTI (Residents #106 and 120). In addition, Resident #120 had no leg bag in place when out of bed as ordered by the physician. The facility policy and procedure (P&P) titled Catheter, Daily Care, (Indwelling) dated 4/2018 documented residents with indwelling catheters will have daily cleansing of the catheter tubing and perineal area for the purpose of preventing urinary tract infections. Ensure the drainage bag is inside a privacy bag. Attach…

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

Based on observation, interview, and record review completed during the Standard survey conducted 9/27/22 through 10/3/22, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #88) of five residents reviewed for unnecessary medications. Specifically, a physician order to discontinue the antipsychotic medication Quetiapine Fumarate (Seroquel) was not implemented, which caused the resident to receive the medication without adequate indication for continued use. The finding is: Review of facility policy and procedure (P&P) titled Psychotropic Drugs last modified 7/6/18, documented residents prescribed psychotropic drugs will receive only those medications, in doses and for duration clinically indicated to treat the resident's assessed condition(s). Re-evaluation of medications by the medical provider may be indicated during routine order renewals and upon any irregularity identified in the consultant…

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

Based on observation, interview and record review conducted during a Standard survey started 9/27/22 and completed on 10/3/22 the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Units one and two) of four resident units reviewed for food temperatures during meals had issues involving food items that were not served at safe and appetizing temperatures. Residents #1, #14, #63 and #73 were involved. The findings are: Review of the facility Policy and Procedure (P&P) titled Food Temperature Requirements and Holding Time dated 6/28/19 documented steamtable thermostats will be turned on 30 minutes prior to meal service and set to maintain hot food between 140-160° F (degrees Fahrenheit). Cold food items should be held in an appropriate container or bin to maintain the temperature below 41 degrees. a. During an interview on 9/27/22 at 10:36 AM, Resident #63 stated staff poured the coffee and let it sit on the table and then it gets cold, most of the food is lukewarm and bland. 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.