Apex Rehabilitation & Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, in accordance with accepted professional standards and practices, the facility did not maintain medical records on each resident that were complete. This was identified for one (Resident #151) of one resident reviewed for Dialysis. Specifically, there was no documented evidence in the treatment administration record that Resident #151's right chest Permacath (a long-term catheter used for dialysis treatment) was monitored every shift for signs and symptoms of bleeding, placement, and skin integrity. The finding is: The facility's policy titled Dialysis last reviewed in July 2023, documented that the shunt site (a surgically created connection between an artery and a vein, used for hemodialysis) or vascular access site will be checked every shift and documented on the Treatment Administration Record by the Nurse. The Nurse will check for bruit/thrill ( signs that the fistula or graft is…

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 interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/16/2025, the facility did not ensure it established an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident #321) of one resident reviewed for Transmission-Based Precautions and for one (Resident #43) of five residents observed during the Medication Administration Task. Specifically, 1) Resident #321 had a Physician's order for Contact Precautions for Shingles (a rash caused by the virus that causes Chickenpox) with an antiviral medication; however, there was no Contact Precautions signage posted in a conspicuous location outside the resident's room that instructs staff and visitors for use of specific Personal Protective Equipment. 2) Medication/Treatment Nurse #2 did not perform hand hygiene before putting on and removing their gloves when performing a finger stick blood glucose…

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 reviews and interviews conducted during a complaint investigation, Complaint # NY00313313 initiated on 2/21/2024 and completed on 2/27/2024, the facility did not ensure that pain management was provided, consistent with professional standards of practice, the comprehensive persons-centered care plan, and the resident's goal and preferences. This was identified for one (Resident #1) of three residents reviewed for pain management. Specifically Resident #1 suffered pain following a fall, rating it at a level of 10 out of 10 (0 indicating no pain 10 indicating most severe). Resident #1 had an physician's order for pain medication to address moderate to severe pain, the nurse did not administer the medication nor notify the doctor of the resident's new pain after the fall. As a result, the resident endured three hours without any pain management until being transferred to the Emergency Department. The resident was admitted for hip fracture. The findings are: The facility's policy titled…

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, records review, and interviews during Recertification Survey and Abbreviated Survey (NY 00319371) initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that a clean, comfortable, and homelike environment was maintained for each resident. This was identified for four (Resident #146, Resident #85, Resident #104, and Resident #93) of four residents reviewed for Environment. Specifically, 1) Resident #146's room was observed on 2/6/2024 and 2/7/2024; the room furniture and the sink vanity were not in good repair with detached base molding, missing drawers, and rusty exposed metal parts. 2) Resident #85's room was observed on 2/6/2024 and 2/7/2024. The room furniture and the sink vanity were not in good repair with missing drawers and a nonfunctioning bureau. 3) Resident #104's room was observed on 2/6/2024 and 2/7/2024. The furniture in the room was not in good repair as evidenced by drawers without a handle, drawers that could not be opened, and missing drawers. 4)…

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 interviews conducted during a Recertification and abbreviated Survey (NY 00318188) initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision to prevent accidents. This was identified for one (Resident #146) of 11 residents reviewed for Accidents/elopement, 2) for six (Resident #93, Resident #104, Resident #146, Resident #103, Resident #112, and Resident #85) of eleven residents reviewed for Accidents hazards; and 3) for one Unit 1A of four units observed during the Medication Storage Task. Specifically, 1) Resident #146, who had a diagnosis of Dementia and was identified by the facility as an elopement risk/wanderer, wandered outside of the facility on 6/11/2023 after being directed to an outdoor area by the receptionist. The resident left the facility without staff knowledge and was brought back by the local police after…

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, records review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys. This was identified for one unit (Unit 1A) of four units observed during the Medication Storage Task. Specifically, during an observation of the medication storage on 2/14/2024, the medication closet on Unit 1A was observed without a lock. The medication closet door had no locking mechanism installed on the door. The storage closet had multiple medications, syringes, and intravenous medication bags stored. The finding is: The facility's policy titled, Medication Storage last reviewed October 2023, documented all drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). Only authorized personnel would have access to the keys to locked compartments. During a tour of the facility's medication storage on Unit 1A 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 interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately to the New York State Department of Health, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. This was Identified for one (Resident #98) of 11 residents reviewed for Accidents. Specifically, on 11/24/2023 Resident #98 was identified with an injury of unknown origin. There was no documented evidence that the injury was reported to the New York State Department of Health as required. The facility's policy titled, Abuse Prevention effective 11/2/2022 and last revised 6/1/2023 documented that 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 record review and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure that all incidents including the injury of unknown origin were thoroughly investigated . This was identified for one (Resident #98) of 11 residents reviewed for Accidents. Specifically, on 11/24/2023 at 8:00 AM Resident #98 was observed with an injury of unknown origin and the facility did not thoroughly investigate the incident to identify the root cause of the injury and to rule of Abuse, Neglect, and Mistreatment. The finding is: The facility's policy titled, Accident/Incident last revised December 2023, documented that all injuries of unknown sources will be investigated. The facility's policy titled, Abuse Prevention effective 11/2/2022 and last revised 6/2023 documented the facility will investigate all incidents of alleged and actual abuse, complaints/grievances, misappropriation, and injuries of unknown origin. The investigative process will 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflects the resident's status. This was identified for one (Resident #61) of one resident reviewed for Dialysis. Specifically, the Minimum Data Set assessment for Resident #61 did not accurately capture that the resident was receiving dialysis treatment. The finding is: The facility policy and procedure titled, MDS 3.0, last reviewed 10/2023, documented that residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. Resident #61 was admitted with diagnoses including Cancer, End-Stage Renal Disease (ESRD), and Dependence on Renal Dialysis. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Section O of the Minimum Data Set 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This was identified for one (Resident #152) of 35 sampled residents. Specifically, a quarterly Minimum Data Set assessment was completed on 12/20/2023 for Resident #152. There was no documented evidence that a care plan meeting was held after each assessment including both the comprehensive and quarterly review assessments. The resident or their representative were not provided notice of a care plan meeting for an opportunity to attend and participate. In addition, Resident #152's comprehensive care plan related to Resident/Family participation in assessment and care planning and Satisfaction with the current plan of care were not reviewed and revised upon the quarterly Minimum Data Set assessment dated [DATE]. The finding is: The facility's policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain personal hygiene. This was identified for one (Resident #122) of two residents reviewed for Activities of Daily Living. Specifically, on 2/6/2024 Resident #122 was observed with long, dirty, and jagged fingernails with a brown substance under the nails on both hands. The finding is: The facility's policy titled, Job Description-Certified Nursing Assistant, dated January 2015, documented the primary purpose of the Certified Nursing Assistant is to provide each of your residents with routine daily nursing care and services in accordance with the resident's assessment and care plan including assisting with nail care (clipping, trimming, and cleaning the finger/toenails). Note: does not include diabetic residents. Resident #122 was admitted…

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 initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified for three (Unit 1A, Unit 2A, and Unit C) of four Units during the Sufficient Staffing Task review. Specifically, a review of the Payroll Based Journal (PBJ) Staffing Data Report, the Facility Assessment, review of weekend staffing and staffing during the Recertification Survey revealed the facility had insufficient nursing staff on numerous occasions. The finding is: The Facility's Staffing Policy and Procedure dated October 2023 documented the facility will maintain safe staffing levels and that the nursing department will schedule and arrange staff according to the acuity and census of each unit to ensure quality of care is maintained. The employees who call out sick will always be replaced 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 interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure that nurse's aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This was identified for one (Resident #48) of two residents reviewed for Choices. Specifically, Certified Nursing Assistant #8 was observed utilizing a sink as a basin to store the water for providing care to Resident #48 in a semi-private room. The sink is also utilized by other residents for handwashing and other hygiene tasks. The finding is: The facility Activity of Daily Living (ADL) Policy dated 6/2023 documented to perform a bed bath, the nursing assistant will secure the bath supplies and clean bed linens as needed and bring them to the resident/patient's bedside. Resident #48 was admitted with diagnoses that included Vascular Dementia, Adult…

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 during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024 the facility did not ensure each resident received radiology services in a timely manner. This was identified for one (Resident #48) of two residents reviewed for Choices. Specifically, Resident #48 had a Physician's order for pacemaker checks every three months and there was no documented evidence that the pacemaker checks were completed as per the Physician's order since 10/4/2023. The finding is: The facility Pacemaker Policy, last reviewed on 6/2023, documented the charge nurse was responsible for ensuring that pacemaker/automated implantable defibrillator (AICD-a device inserted into the chest to help fix fast, abnormal heart rhythms) checks are conducted and reported in compliance with Physician's orders every 3 to 6 months. Resident #48 was admitted with diagnoses that included Atrial Fibrillation, Hypertension, and Presence of a Cardiac Pacemaker. A Quarterly Minimum Data Set…

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 during the Recertification Survey, initiated on 2/6/2024 and completed on 2/14/2024, the facility did not ensure each resident received routine dental services to meet the needs of each resident. This was identified for one (Resident #147) of two residents reviewed for Dental Services. Specifically, Resident #147 was admitted to the facility with full upper and lower dentures. The resident lost the upper dentures while a resident at the facility. A dental consult dated 1/11/2023 documented that a preliminary impression for the lost dentures would take place at the next session. There was no documented evidence that the preliminary impression for the upper dentures was completed. In addition, the resident was not offered to use their lower dentures, as the lower dentures were being stored in the medication cart and the facility staff did not know the whereabouts of the resident's lower dentures. The finding is: The facility's Dental Policy dated October 2023,…

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 interviews during the Recertification Survey initiated on 2/6/2024 and completed on 2/14/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #383) of two residents reviewed for Transmission-Based Precautions, one (Resident #48) of two residents reviewed for Choices, and one (Resident #60) of two residents reviewed for pressure ulcers. Specifically, 1) the facility did not ensure that an employee (Certified Nursing Assistant #3) wore the appropriate Personal Protective Equipment (PPE) in Resident #383's room who was on Contact and Droplet Precautions for COVID-19 infection. 2) Certified Nursing Assistant #8 was observed using the room sink as a water basin to provide hygiene care to Resident #48. The resident shares a room with another resident who also utilizes the sink for hygiene and hand washing.…

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 interviews during the Recertification Survey completed on 2/14/2022 the facility failed to ensure an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections was maintained. This was identified for two (Resident #4 and Resident #154) of four residents reviewed for Skin Conditions and one (Resident #53) of three residents reviewed for Pressure Ulcers. Specifically, 1) during the wound care observation of Resident #4's right lateral leg wound, right heel, and plantar foot wounds the Registered Nurse (RN) #6 did not perform hand hygiene and did not change gloves after cleaning the leg wounds. Additionally, after cleaning the heel and plantar wounds, RN #6 allowed the wounds to come in contact with a dirty surface. 2) During an observation of Resident #53's left heel ulcer treatment, RN #6 allowed the cleansed wound to come in contact with a dirty surface; and 3) during Resident #154's head wound care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey completed on 2/14/2022, the facility did not ensure that a comprehensive person- centered care plan (CCP) was developed to meet the resident's medical and nursing needs to include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #222) of three residents reviewed for Pressure Ulcers. Specifically, Resident #222 who had a Stage 3 Pressure Ulcer to the sacral area upon admission and was identified as requiring two person staff assistance for bed mobility. The resident's CCP did not have specific interventions to address turning and positioning needs. The finding is: Resident #222 was admitted to the facility on [DATE] with diagnoses including Stage 3 Pressure Ulcer to the Sacral Region. The Five-Day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS)…

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 during the Recertification Survey completed on 2/14/2022, the facility did not ensure that each resident received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #4) of four residents reviewed for skin conditions. Specifically, during the observation of Resident #4's right plantar foot wound care the Registered Nurse (RN) #6 did not pack the wound with the Iodoform wound packing as per the Physician's order. The finding is: The facility's policy titled, Wound Treatment Administration, last reviewed 1/2022, documented to provide evidenced-based treatments in accordance with current standards of practice and physician's orders. The policy further documented that the wound treatments will be provided in accordance with physician and physician-extender orders, including cleansing method, type of dressing, and frequency of dressing change. Resident #4 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey completed on 2/14/2022, the facility did not ensure that all resident's environment was free from accident hazards. This was identified for one (Resident #152) of eight residents reviewed for Accidents. Specifically, Resident #152, who was ambulatory, was not moved out of their room while there were repairs being made for an active leak. Staff did not ensure that signage indicating the wet floor was in place to alert the resident of the wet floor. The finding is: The Accident/Incident facility policy dated 1/2022 documented that it is the policy of the facility to maintain the safety of all residents. In compliance with the New York State Department of Health regulation, the resident environment remains free of accident hazards. Professional staff members will recommend, institute and update plan of care with preventative measures to ensure resident's safety. The policy documented hazards include wet floors that are 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 observations, record review, and staff interviews during the Recertification Survey completed 2/14/2022, the facility did not ensure that each resident who needs respiratory care was provided such care, consistent with professional standards of practice, for one (Resident #17) of two residents reviewed for Respiratory Care. Specifically, Resident #17 was observed receiving oxygen therapy without a physician's order. The finding is: The facility's policy titled Oxygen Administration, last reviewed in January 2022, documented oxygen administration shall be initiated under orders of a physician or physician-extender, except in the case of an acute need. In such cases, oxygen is administered and orders for oxygen are obtained as soon as is able. Resident #17 was admitted to the facility with diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, and Hypoxemia. The 11/7/2021 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that 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.