McCrea Manor Nsng And Rehab Ctr LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to honor Resident #3's choice in showers. This affected one (Resident #3) of three residents reviewed for resident rights Finding include: Review of Resident #3's open medical record revealed diagnoses including chronic kidney disorder, bipolar disorder, major depressive disorder, generalized muscle weakness, need for assistance with personal care and contracture. A care plan initiated 01/09/23 indicated Resident #3 needed assistance from staff to meet Activities of Daily Living (ADL) needs related to impaired mobility with decreased physical functioning and general debility following hospitalization with lymphedema and multiple wounds. Interventions included assisting Resident #3 with bathing as needed per resident's preference. A nursing note dated 03/15/25 at 11:51 P.M. indicated Resident #3 was offered a shower by staff during the shift. Resident #8 refused. The nurse spoke with Resident #3's Power of Attorney (POA) via Resident #3's personal…

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

Based on observation, medical record review, and interview, the facility failed to ensure ordered medication was available for administration. This affected three residents (Resident #15, #31, #32) of three residents reviewed for pharmacy services. Findings include: 1. On 04/09/25 at 8:45 A.M., Licensed Practical Nurse (LPN) #100 was observed administering medication to Resident #31. As LPN #100 was preparing the medications she verified Resident #31 did not have Clopidrogel (anti-platelet) available for administration. 2. Review of Resident #15's open medical record revealed diagnoses including type two diabetes mellitus with a foot ulcer, generalized muscle weakness, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), polyneuropathy, hyperlipidemia, morbid obesity, anxiety, depression, non-pressure chronic ulcer of the right foot, and protein-calorie malnutrition. Review of the March 2025 Medication Administration Record (MAR) revealed an electronic MAR note on 03/12/25 indicating Losartan Potassium, Amlodipine and another unspecified medication…

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, review of physician orders, review of manufacturer information, policy review and interview, the facility failed to administer medication as ordered and/or in accordance with manufacturer guidance. Four medication errors out of 31 opportunities for error were identified resulting in a 12.9% error rate. This affected two (Residents #31 and #68) of six residents observed for medication administration. Findings include: 1. Review of Resident #31's physician orders revealed Clopidrogel bisulfate 75 mg was ordered once a day in the morning. The start date was 02/15/25. Review of physician orders indicated an order dated 02/18/25 for one multivitamin every day in the morning, with no indication for minerals. On 04/09/25 Licensed Practical Nurse (LPN) #100 was observed preparing medication for administration to Resident #31 at 8:45 A.M. During the preparation, LPN #100 stated she had no Clopidrogel bisulfate (anti-platelet) 75 milligrams (mg) available for administration. LPN #100 verified she 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 observation and interview, the facility failed to ensure food was served at a palatable, safe temperature. This affected one (Resident #37) of seven residents interviewed regarding the lunch meal served on 04/07/25. Findings include: On 04/07/25 between 11:15 A.M. and 12:02 P.M., the lunch tray line was observed. Incorrect information was provided to the surveyor regarding carts that had been served. At 12:02 P.M., the cook indicated she only had three trays lift to serve but they were waiting on residents to indicate if they were going to the dining room or eating in their rooms. Meals were prepared and placed in the warmer. On 04/07/25 at 12:03 P.M., a test tray was prepared directly from the steam table. The temperature of the fish was 111 degrees Fahrenheit. [NAME] #120 stated the fish should have been 145 degrees when served. The fish tasted cool. On 04/07/25 at 1:53 P.M., Resident #37 reported she did not like the fish served for lunch. It was cold and did not taste good. Review of the facility's Food Temperature Guidelines (revised August 2008) revealed hot foods…

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 review of medical records, policy review and interview, the facility failed to ensure medical records were complete to accurately reflect medications being administered or not. This affected two (Residents #15 and #17) of three residents reviewed for medication administration. Findings include: 1. Review of Resident #15's open medical record revealed diagnoses including type two diabetes mellitus with a foot ulcer, generalized muscle weakness, gastroesophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), polyneuropathy, hyperlipidemia, morbid obesity, anxiety, depression, non-pressure chronic ulcer of the right foot, and protein-calorie malnutrition. Review of the March 2025 Medication Administration Record (MAR) revealed no documentation of morning medications being administered on 03/13/25. Ordered medications included mag ox (supplement) 400 milligrams (mg), Fluoxetine (antidepressant) 40 mg, Buspirone (anti-anxiety) 10 mg, Pantoprazole sodium (used to reduce stomach acid production) 40 mg, Metformin (anti-diabetic) 750 mg, Meloxicam…

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, medical record review, review of Self-Reported Incident, review of witness statement, policy review and interview, the facility failed to ensure staff provided appropriate dementia care when Resident #57, who had a diagnosis of dementia with mood disturbance/other behavioral disturbances and resided on the secured memory care unit, began to display resistive-to-care behaviors. This affected one (Resident #57) of three residents reviewed for dementia care. Sixteen residents (Residents #66, #62, #55, #52, #40, #57, #37, #49, #15, #68, #21, #45, #47, #41, #28 and #23) had a diagnosis of dementia and resided in the secured memory care unit. The census was 70. Findings include: Review of the medical record for Resident #57 revealed an admission date of 04/09/23 with diagnoses of Alzheimer's disease, dementia with mood disturbance, dementia with other behavior disturbances, and anxiety disorder. Resident #57's power of attorney (POA) was his wife. Resident #57 resided on the secured memory 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.

Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. This had the potential to affect 110 of 111 residents receiving food from the kitchen. Resident #45 was identified as receiving no food from the kitchen. The facility census was 68. Findings include: Initial tour of the kitchen on 08/25/24 from 8:10 A.M. to 8:32 A.M. with Dietary Manager (DM) #238 revealed the floor was dirty with food splatter, pieces of paper, and dried food debris especially underneath equipment. The microwave had food splatter on all sides of the microwave and had burnt food on the bottom. The grill had food residue on it and the grill pan was filled with french fries and food pieces. The prep table that the grill was sitting on had food debris on it. Dietary Manager (DM) #238 stated that the grill was electric and there was no power for it, so they did not use it for cooking. Observation inside the walk-in refrigerator revealed an undated food container on the floor with no label to identify what was inside of it. In addition,…

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, interview and record review, the facility failed to ensure residents were provided activities on the memory care unit. This affected 15 ( #8, #11, #16, #24, #26, #27, #35, #42, #44, #47, #49, #52, #53, #55, and #57) of 16 residents residing on the memory care unit. Resident #31 was identified as a resident taken off the memory care unit for activities. The facility census was 68. Findings include: Observation on 08/26/24 at 3:02 P.M. of the memory care dining room revealed the television was on the music channel, few residents were sitting at the tables, and agency State Tested Nursing Assistant (STNA) #500 was sitting at a table eating potato chips, drinking pop, and looking at her phone. STNA #500 stated she was on a small break and not there to do activities. Observation and interview on 08/26/24 at 3:30 P.M. revealed STNA #236 was coming out of a male resident's room and standing near the doorway. STNA #236 stated that she was trying to redirect a female resident out of the male resident's room. STNA #236 stated that she was standing at the doorway to keep…

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, medical record review, interview, and review of facility policy, the facility failed to ensure Resident #9's wound related treatments were implemented as ordered; Resident #18's skin was assessed and treatments were applied as ordered; Resident #34's thrombo-embolic deterrent (TED) hose and geriatric sleeves were implemented as ordered; and Resident #45's percutaneous endoscopic gastrostomy (PEG) tube dressing was implemented as ordered. This affected three (Residents #9, #18 and #34) of three residents reviewed for general skin conditions; and one (Resident #45) of one resident reviewed for PEG tube care. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 05/25/23 with diagnoses including type two diabetes mellitus with other circulatory complications, diabetic neuropathy, intervertebral disc degeneration of the lumbar region, fibromyalgia, depressive disorder, and stage three kidney disease. Review of the active diagnoses further revealed 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 medical record review, interview, and review of facility policy, the facility failed to ensure resident comprehensive care plans were updated and individualized, or that staff were aware of the resident's current smoking status and interventions. This affected four residents (#9, #13, #17 and #31) of six residents (#9, #13, #17, #31, #52, and #59) who were reviewed for smoking. The facility also failed to ensure Resident #53 was free of accidents hazards. This affected one out of three residents reviewed for falls ( #8, #53, and #59). The facility census was 68. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 05/25/23 with diagnoses including type two diabetes mellitus with other circulatory complications, diabetic neuropathy, intervertebral disc degeneration of the lumbar region, fibromyalgia, depressive disorder, diabetic foot ulcer, unspecified wound to the left lower leg, and stage three kidney disease. Review of the quarterly Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure contact isolation was maintained as ordered for Resident #50. This affected 12 residents who resided on the B unit where Resident #50 resided (Residents #1, #3, #4, #20, #28, #29, #30, #39, #54, #58, #59 and #115). Facility census was 68. Findings include: Review of Resident #50's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia and heimparesis, bipolar disorder and polyneuropathy. Review of Resident #50's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #50's physician orders revealed an order dated 08/30/24 for contact isolation due to active herpes simplex virus (HSV) outbreak. Observation of the signage of Resident #50's door on 08/25/24 at 2:40 P.M. revealed the resident was in enhanced barrier precautions. Interview on 08/25/24 at 3:04 P.M. with the Director of Nursing (DON) confirmed the signage on 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 Based on observation, record review and interview, the facility failed to ensure Residents #4 and #19's pressure ulcer wound care was completed as ordered. This affected two ( #4 and #19) of two residents reviewed for pressure ulcer wounds. Findings include: 1. Review of Resident #4's medical record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypercapnia, multiple sclerosis and chronic pain syndrome. Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #4's skin care plans revealed an intervention dated 07/24/24 for treatments as ordered by the physician. Resident #4 was discharged to the hospital on [DATE] and returned on 07/24/24. Review of Resident #4's Pressure Ulcer Risk Assessment form dated 07/23/24 revealed the resident's pressure sore risk was 15 or low risk of developing pressure ulcer wounds. Review of Resident #4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident's oxygen flow rate was set as ordered by the physician. This affected one (Resident #34) of two residents reviewed for respiratory care. The facility identified nine residents who received oxygen therapy. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, asthma, dementia, diabetes mellitus, congestive heart failure, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/24, revealed Resident #34's Brief Interview for Mental Status (BIMS) score was 14, which indicated intact cognition. There were no behaviors or rejection of care. The resident received oxygen therapy. Review of the Care Plan, dated 10/16/23, revealed Resident #34 was at risk for alteration in air exchange with the intervention to administer oxygen as ordered. Review of physician order, dated…

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

Based on observation and interview, the facility failed to ensure Resident #34's room was maintained in good repair. This affected one (#34) of 22 residents reviewed for environmental concerns. Facility census was 68. Findings include: Observation of Resident #34's room on 08/28/24 at 1:00 P.M. with Maintenance Director #2115 revealed four holes in the drywall which appeared recessed behind the resident's recliner and the electrical outlet was damaged and recessed into the wall. Interview on 08/28/24 at 1:02 P.M. with Maintenance Director #2115 confirmed Resident #34's room was not maintained in good repair.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure Residents #14 and #24 were provided appropriate transportation for scheduled appointments. This finding affected two (Residents #14 and #24) of three residents reviewed for appointments. Findings include: 1. Review of Resident #14's medical record revealed the resident was admitted on [DATE] with diagnoses including multiple sclerosis, major depressive disorder and weakness. Review of Resident #14's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #14's physician orders revealed an order dated 12/26/23 for surgery for a nephrostomy tube placement with the time to be determined. Review of Resident #14's Appointment form dated 12/26/23 revealed the resident was scheduled to go to the radiology department for surgery. Review of Resident #14's progress note dated 12/26/23 at 12:47 P.M. authored by the Director of Nursing (DON) indicated Resident #14's doctor office was called 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.

Based on observation and staff interview, the facility failed to ensure staff were competent to identify and use the emergency release features of mechanical hoyer lift devices. This had the potential to affect all 24 residents (#6, #8, #12, #14, #15, #16, #17, #18, #21, #23, #24, #26, #27, #28, #38, #41, #43, #44, #48, #52, #53, #55, #58, and #63) who required a mechanical hoyer lift for transfers. The census was 63. Findings include: On 12/21/23 at 12:33 P.M., observation revealed State Tested Nurse Aide (STNA) #104 and STNA #183 transferred Resident #27 from his wheelchair to his bed using a mechanical hoyer lift device. Observation of the device revealed it had a pin hole emergency release button next to the red emergency stop button on the side of the device. On 12/21/23 at 12:45 P.M., observation of STNA #104 and STNA #183 revealed they were unable to identify the emergency release button on the device they had used to transfer Resident #27. Interview at the time of observation with STNA #104 and STNA #183 both stated the device did not have an emergency release button. Review…

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, the facility failed to ensure resident lift devices had functioning locking wheels. This had the potential to affect three (Residents #5, #7 and #13) identified as utilizing a sit to stand lift device for transfer assistance. The facility census was 62. Findings include: Observation on 08/07/23 at 9:40 A.M. revealed a sit to stand lift (assistive device permitting transfer between bed and chair or other similar resting places by the use of hydraulic or electric power) in the hallway of the facility. Observation revealed the left rear wheel/caster to have a missing and non-functional lock. The missing lock caused the sit to stand lift to spin in a circle due to the locked right wheel and missing left wheel lock. On 08/07/23 at 9:53 A.M. interview with Maintenance Director (MD) #75 verified the sit to stand lift was missing the lock device for the left rear wheel causing the devices to be unsteady when used. On 08/07/23 at 10:00 A.M. interview with Registered Nurse (RN) #82 also verified the sit to stand lift was missing the lock device for…

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

Based on record review and staff interview, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) meetings were held every quarter. This had the potential to affect all residents. The facility census was 47. Findings include: Review of the facilities sign-in sheet for the QA meeting minutes for the meetings held on July 2021 to April 2022 revealed no evidence the Quality Assurance (QA) meetings were held as required. Interview with the Administrator on 07/14/22 at 9:24 A.M. verified the QAPI meetings were not held from July 2021 to April 2022. The Administrator verified QAPI meetings are to be held every quarter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a dignified dining experience for five residents (Resident #3, #4, #36, #37 & #44) of 17 residents reviewed for dignity. The facility census was 47. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 07/21/21 with diagnoses of Alzheimer's Disease, gastro-esophageal reflux disease (GERD), chronic kidney disease and polyosteoarthritis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was totally dependent on staff for eating. 2. Review of the medical record for Resident #4 revealed an admission date of 02/22/19 with diagnoses of depression, anemia, dementia and hypothyroidism. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #4 was totally dependent on staff for eating. 3. Review of the medical record for Resident #36 revealed an admission date of 09/07/12 with diagnoses of dementia, depression, anemia and dysphagia. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure families/representatives were notified in writing of resident transfers to the hospital. This affected three Residents (Resident #9, #33 and #46) of three Residents reviewed for hospitalizations. The facility census was 47. Findings included: Review of the medical record for Resident #9 revealed an admission date of 06/23/22 with diagnoses of dementia, schizoaffective disorder, diabetes and anxiety. Review of a progress note dated 05/26/22 revealed the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of both the electronic and paper charts revealed no evidence the resident's emergency contact was notified in writing of the discharge. Review of the medical record for Resident #33 revealed an admission date of 08/13/20 with diagnoses of dementia, psychosis, depression and Alzheimer's. Review of a progress note dated 07/07/22 the resident was transferred to the hospital on [DATE] and returned 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #25 and #36 had a comprehensive care plan developed and implemented to meet their care and service needs. This affected two (#25 and #36) of 17 residents reviewed for a comprehensive care plan. The facility census was 47. Findings include: 1. Review of the medical record for Resident #25 revealed an admission dated of 04/29/22 with diagnoses including essential hypertension, major depressive disorder, anxiety disorder, and bipolar disorder. Review of Resident #25's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed Resident #25 had intact cognition and it was very important to Resident #25 to have reading materials, be able to listen to music, and to keep up with the news. Review of Resident #25's Activity assessment dated [DATE] revealed Resident #25 had an interest in reading, gardening, music, exercise, shopping, and watching television/movies. Review of Resident #25's social services notes dated 05/02/22 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 record review and interview, the facility failed to ensure Resident #33's laboratory blood tests were completed as ordered. This finding affected one (Resident #33) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #33's medical record revealed he was readmitted on [DATE] with diagnoses including epilepsy, developmental disorder of scholastic skills and unspecified intellectual disabilities. Review of Resident #33's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Review of Resident #33's physician orders revealed an order dated 07/09/21 for Depakote delayed release 500 mg (milligrams) give two tablets by mouth two times a day related to epilepsy; an order dated 07/20/21 for Phenobarbital 30 mg give one tablet by the mouth in the morning related to epilepsy; an order dated 07/09/21 for Vimpat 200 mg give one tablet by mouth two times a day related to epilepsy; an order dated 08/05/21 to obtain a Vimpat blood level every…

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.