Beavercreek Health And Rehab

Based on observation, staff interview, and policy review, the facility failed to ensure dairy products were served at the appropriate temperature. This had the potential to affect 68 residents in the facility. The facility identified two residents (#08 and #21) who did not receive food from the kitchen. The facility census was 70. Findings include: Observation on 09/25/34 at 8:06 A.M. of the dining area on the facility's Red unit revealed fifteen trays lined up on the counter. Each tray contained a meal ticket, silverware, insulating covers, and a carton of milk. Observation on 09/25/24 at 8:25 A.M. revealed dietary staff started trayline, plating food and placing it in the insulated covers. Continued observation revealed nine trays were placed on a cart and delivered to the residents by the staff. Further observation revealed dietary staff placed an additional four trays on a cart for delivery. Observation on 09/25/24 at 8:41 A.M. revealed the milk on the tray of Resident #23 was 46.6 degrees Fahrenheit. Interview at the same time, Dietary Aid (DA) #349 verified the milk 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, staff interview, and policy review, the facility failed to ensure food was stored and prepared in a manner to prevent against the potential spread of foodborne illness. This had the potential to affect 68 residents in the facility. The facility identified two residents (#08 and #21) who did not receive food from the kitchen. The facility census was 70. Findings include: 1) Observation on 09/23/24 at approximately 8:20 A.M. of the facility's walk-in cooler revealed gray and white speckled areas throughout the eight wire shelves and several plastic milk crates. Further observation revealed a puddle of brown liquid, measuring approximately two feet by two feet, on the floor below a box of potatoes, which was positioned on the lowest shelf of a wire rack. A large box of cucumbers was observed on the top shelf of the rack and was leaking onto the shelves below and into the box of potatoes. Interview at the same time, Dietary Staff (DS) #306 stated the gray and white speckled areas throughout the cooler were mold and stated it had just started. DS #306 verified the…

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

Based on resident interviews, staff interviews, and record review, facility failed to document and follow up on resident concerns from the resident council meetings. This affected seven (#09, #19, #26, #30, #56, #62, and #221) residents who participated in resident council. The facility census was 70. Findings include 1) Review of the medical record for Resident #09 revealed an admission date of 05/06/19. Resident #09 was cognitively intact. 2) Review of the medical record for Resident #19 revealed an admission date of 10/25/21. Resident #19 was cognitively intact. 3) Review of the medical record for Resident #26 revealed an admission date of 02/05/24. Resident #26 was cognitively intact. 4) Review of the medical record for Resident #30 revealed an admission date of 01/27/20. Resident #30 was cognitively intact. 5) Review of the medical record for Resident #56 revealed an admission date of 02/27/24. Resident #56 was cognitively intact. 6) Review of the medical record for Resident #62 revealed an admission date of 03/12/24. Resident #62 had mild cognitive impairment. 7) Review 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 observation, record review, and staff interviews, the facility failed to treat all residents with dignity and respect. This affected two (#28, and #29) of three residents reviewed for dignity. The facility census was 70. Findings Include: 1) Review of Resident #28's medical record revealed an admission date of 07/24/24. Diagnoses included dysphasia, atrial fibrillation, and hemiplegia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 was severely cognitively impaired and required substantial assistance with eating. Observation of Resident #28 on 09/23/24 at 11:30 A.M., revealed he was in the dining room/lounge area with other residents and the afternoon meal was being served by the staff. All the other residents were served their lunch, and they were eating with the exception of Resident #28. Resident #28 continued to face the other residents as they were eating, including another resident seated at the same table. At 12:10 P.M., Resident #28 still wasn't…

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, staff interview, and policy review, the facility failed to ensure accuracy of code status in the medical record. This affected three (#29, #32, and #58) of nineteen residents reviewed for advanced directives. This had the potential to affect all 70 residents in the facility. Findings include: 1) Review of the medical record of Resident #58 revealed an admission date of 06/27/23. Diagnoses included metabolic encephalopathy, alcoholic cirrhosis of liver, respiratory failure, chronic obstructive pulmonary disease (COPD), anxiety, depression, obsessive-compulsive disorder (OCD), and hypertension. Review of the Do Not Resuscitate (DNR) order form located in the paper (hard) chart dated 09/28/23 for Resident #58, revealed the resident was to be a DNR-Comfort Care-Arrest (CCA). Review of the physician orders in the electronic medical record (EMR) for Resident #58 revealed an order dated 10/05/23 for the resident to be a Full Code. Interview on 09/23/24 at 3:45 P.M., Licensed Practical…

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, staff interview and record review, the facility failed to ensure residents had to a safe, clean, comfortable and homelike environment. This affected one (#18) resident of one reviewed for physical environment. The facility census was 70. Findings include Review of the medical record for Resident #18 revealed an admission date of 03/22/19. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, dysphagia, heart failure, unspecified psychosis, respiratory failure and morbid obesity. Observation on 09/23/24 at 1:18 P.M., revealed Resident #18 had a large hole in the drywall behind her bed. Resident had a bariatric bed and a board affixed to the wall behind her bed to protect the drywall from damage from the bed. On the right side of the board was damage to the drywall with estimated size of about six inches by 18 inches. Interview on 09/26/24 at 12:50 P.M. with Maintenance Director (MD) #364, verified damage to the drywall. MD #364 revealed he had not been informed of the damage. MD #364 stated the damage was significant enough where a patch…

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, staff interview, and policy review, the facility failed to ensure residents were provided with notification indicating the reason for transfer upon a transfer to the hospital. This affected three (#21, #43, and #56) residents of the four residents reviewed for hospitalization. The facility census was 70. Finding included: 1) Review of the medical record for Resident #43 revealed an admission date of 12/07/24. Diagnoses included osteomyelitis of vertebra, heart failure, cellulitis, kidney failure, and edema. Review of Resident #43's admission census record revealed the resident was hospitalized from [DATE] to 03/13/24, again from 04/13/24 to 05/06/24 and 08/13/24 to 08/14/24. Further record review found no documented evidence of Resident #43 nor Resident #43's representative being provided with a notification for reason of transfer for any of these three hospitalizations. 2) Review of the medical record for Resident #56 revealed an admission date of 02/27/24. Diagnoses included cerebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, facility failed to ensure residents were provided with bed hold notification upon a transfer to the hospital. This affected three (#21, #43, and #56) residents of four residents reviewed for hospitalization. The facility census was 70. Finding included: 1) Review of the medical record for Resident #43 revealed an admission date of 12/07/24. Diagnoses included osteomyelitis of vertebra, heart failure, cellulitis, kidney failure, and edema. Review of Resident #43's census record revealed the resident was hospitalized from [DATE] to 03/13/24 and again from 04/13/24 to 05/06/24. Review of a Bed Hold Notice dated 03/13/2/4 revealed Resident #43 was hospitalized from [DATE] to 03/13/24. The form was provided to the resident on the date of discharge from the hospital and therefore was not provided timely and upon admission to the hospital. Review of a Bed Hold Notice dated 05/06/24 revealed Resident #43 was hospitalized from [DATE] to 05/06/24. The form was provided 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, staff interview, and review of hospital records, the facility failed to allow a resident to return to the facility timely following a hospital stay. This affected one (#43) of four residents reviewed for hospitalization. The facility census was 70. Finding included: Review of the medical record for Resident #43 revealed an admission date of 12/07/24. Diagnoses included osteomyelitis of vertebra, heart failure, cellulitis, kidney failure, and edema. Review of Resident #43 census revealed the resident was hospitalized from [DATE] to 08/14/24. Review of a nurse's progress note for Resident #43 dated 08/13/24 at 4:49 P.M., revealed the resident was sent to hospital for critical laboratory findings (labs) per the Nurse Practitioner (NP). Review of a nurse's progress note for Resident #43 dated 08/14/24 at 10:57 A.M. revealed the resident returned home from the hospital with a new order for Levaquin 500 milligrams (mg) once daily for seven days for urinary tract infection (UTI) and Pneumonia.…

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, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents were provided adaptive equipment as ordered. This affected one (#55) of one resident reviewed for adaptive equipment. The facility identified ten residents who utilized adaptive equipment. The facility census was 70. Findings include: Review of the medical record of Resident #55 revealed an admission date of 05/25/23. Diagnoses included dementia and oropharyngeal dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 had severely impaired cognition. Review of the Speech-Language Pathology (SLP) Discharge summary, dated [DATE], revealed Resident #55 utilized a provale cup for safe intake of thin liquids and was assessed as independent with the use of the provale cup. Review of a physician order for Resident #55 revealed an order dated 03/12/24 for a regular, dysphagia mechanical soft diet with regular liquid consistency and a provale…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of medical records, staff interview, and policy review, the facility failed to ensure a licensed nurse communicated a resident incident, that was later determined to be a fall, to the oncoming licensed nurse to allow for ongoing monitoring and/or potentially prevent further incidents or falls. This affected one (#2) of three residents reviewed for falls. The census was 62. Findings include: Review of Resident #2's medical record revealed an admission date of 10/02/23. Diagnoses listed included anxiety disorder, right femur fracture, atrial fibrillation, hypertension, and repeated falls. Review of a quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. Resident #2 had not had any reported falls. Review of progress notes dated 06/12/24 at 1:14 P. M revealed when nurse went into Resident #2's room to pass medications…

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, observations and staff interviews, the facility failed to ensure treatments (i.e. moon boots) were in place as prescribed. This affected one (#30) of three residents reviewed for treatment implementation. The facility census was 68. Findings include: Review of medical record for Resident #30 revealed admission date of 01/17/23 with a Brief Interview Mental Status (BIMS) score of 13 on 01/11/24 indicating intact cognition. Diagnoses include chronic obstructive pulmonary disorder, heart failure, schizophrenia, depression, dementia with psychotic disturbances and insomnia. Resident #30 remains in the facility. Review of Resident #30's physician orders revealed an order for moon boots to both feet every shift with a start date of 11/02/23. Observation on 01/22/24 with State Tested Nursing Assistant STNA #30 at 3:26 P.M. revealed Resident #30 did not have his moon boots on. STNA #30 verified Resident #30's moon boots were not on and a search of the room revealed they were not present. STNA #30…

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, observations, staff and pharmacy interviews and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#30 and #60) of three residents reviewed for medication administration. Facility census was 68. Findings include: 1. Review of medical record for Resident #30 revealed admission date of 01/17/23 with a Brief Interview Mental Status (BIMS) score of 13 on 01/11/24 indicating intact cognition. Diagnoses include chronic obstructive pulmonary disorder, heart failure, schizophrenia, depression, dementia with psychotic disturbances and insomnia. Resident #30 remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed he required set up for meals, dependent for bathing, toileting and substantial assistance for bed mobility. Observation on 01/23/23 at 10:10 A.M. of medication pass by Assistant Director of Nursing (ADON) #117 for Resident #30 revealed Potassium Chloride (hypokalemia) packet 10 Milliequivalent (MEQ) was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital documentation and staff interview, the facility failed to ensure documentation regarding nursing assessments and/or the circumstances surrounding a residents hospitalization was documented in the medical record. This affected one (#84) of three residents medical records reviewed for hospitalization. Facility census was 68. Findings include: Review of medical record for Resident #84 revealed admission date of 04/26/23. Diagnoses include femur fracture and hypertension. Resident #84 was discharged from the facility to the hospital on [DATE]. The discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #84 required extensive assistance for bed mobility, toileting, transfers occurred only once or twice and eating required supervision. The MDS documented Resident #84 was discharged to an acute hospital. Record review of the progress notes for Resident #84 revealed there was no documentation for his hospitalization, and/or him leaving the facility. Further…

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 the facility menu, observations, resident and staff interviews, review of recipes, the facility failed to provide nutritious and palatable meals to residents. This had the potential to affect 67 residents in the facility who received meals prepared in the kitchen. The census was 68. Findings include: Review of the facility menu dated 12/28/23 revealed the breakfast meal included waffles, sausage, and oatmeal. Observation on 12/28/23 at 8:30 A.M. of the 400 Unit service line for breakfast revealed Dietary Aide (DA) #140 opened a plastic bag of thawed waffles which were sitting in a warmer tray. DA #140 placed a waffle onto a resident's plate. Interview on 12/27/23 at 8:30 A.M. of DA #140 confirmed the waffles came frozen and were steamed in their original packaging and then plated to serve to the residents. Observation of a test tray on 12/28/23 at 8:35 A.M. revealed the frozen waffle was light yellow in color with no toaster marks and was soft and wet. The sausage link was dark brown in color, hard, and difficult to cut. Interview on 12/28/23 at 8:35 A.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and medical record review, the facility failed to ensure a resident had access to their call light. This affected one (Resident #10) of two residents reviewed for call light access. The facility census was 67. Findings include: Review of the medical record for Resident #10 revealed she was admitted to the facility on [DATE] with a diagnoses of nontraumatic intracerebral hemorrhage, hemiplegia affecting left non-dominant side, chronic respiratory failure, chronic obstructive pulmonary disease, atrial fibrillation, and seizures. Resident #10 was paralyzed to the left side of her body. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had cognitive impairment. Her functional status was listed as extensive to totally dependent on staff for all activities of daily living. Observations on 11/02/23 at 12:00 P.M. of Resident #10 with State Tested Nurse Aide (STNA) #161 revealed Resident #10's call light was laying on her paralyzed side, dropped…

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, resident and staff interviews, and record review, facility failed to ensure physician ordered nutritional supplements were provided as ordered. This affected one (Resident #46) of three reviewed for nutritional supplements. The facility census was 71. Findings include Review of the medical record for Resident #46 revealed an admission date of 01/21/19. Diagnoses included heart failure, depression, acute embolism, anemia, anxiety and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively impaired and required limited assistance with eating. Review of Resident #46's physician orders for July 2023 revealed an order dated 06/20/23 for house supplement, 120 milliliters (ml) to be given three times daily. Additionally, there was an active order for a health shake, three times daily with meals. Review of the plan of care dated 06/16/23 revealed Resident #46 was at risk for weight loss and malnutrition with interventions in place 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, observation, policy review, staff interviews, the facility failed to ensure medications were properly stored. This had the potential to affect four residents (#12, #14, #54, and #65) who were cognitively impaired and independently mobile. Findings include: 1. Observation on 01/25/23 7:04 A.M. revealed two unidentified pills in a medicine cup left unattended on the 200 hall medication cart. No staff was noted in the hall. Interview on 01/25/23 at 7:08 A.M. with Licensed Practical Nurse (LPN) #708 verified Protonix (acid reflux) and a multivitamin were left unattended. 2. Observation on 01/30/23 at 10:09 A.M. revealed an unidentified nurse walked away from the medication cart and left the unit. The medication cart was observed unlocked. Interview on 01/30/23 at 10:11 A.M. with Assistant Director of Nursing (ADON) #340 verified the medication cart was left unlocked and unattended. ADON #340 verified medication carts should be locked when unattended. Review of the facility's list of residents revealed Resident #12, #14, #54, and #65 were cognitively impaired and…

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

Based on record review, observation, staff interview, and policy review, the facility failed to ensure staff wore hairnets while in food preparation areas and failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect all residents in the facility who receive food from the kitchen. The facility identified four resident (#10, #11, #55, and #57) who did not receive food from the kitchen. The facility census was 71. Findings include: 1. Observation on 01/23/23 at 7:12 A.M., upon entrance into the kitchen, revealed several dietary staff members standing around the food prep area. Four employees were observed not wearing hairnets: [NAME] #310, Dietary Assistant (DA) #301, [NAME] #300, and [NAME] #315. All employees listed verified they were not wearing hairnets at the time of the observation. Interview on 01/25/23 12:02 P.M. with Dietary Manager (DM) #342 confirmed a hairnet should be applied immediately upon entrance to the kitchen. Review of the facility's undated policy titled Basic Safe Food Handling revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure physician records were readily accessible. This affected six (#4, #26, #38, #50, #70, and #276) of 24 residents reviewed for medical record accuracy. The facility census was 71. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 08/31/21. Diagnoses included cerebral infarction, cellulitis of left lower limb, acute embolism and thrombosis of deep vein of left lower extremity, schizoaffective disorder, depressive type, non-pressure chronic ulcer, type II diabetes mellitus with diabetic dermatitis, anxiety disorder, and major depressive disorder. Review of the medical record from September 2022 to 01/29/23 = revealed physician and/or certified nurse practitioner (CNP) notes were unavailable for review. Interview on 01/30/23 at 4:33 P.M. with Regional Nurse Coordinator #409 verified physician notes for Resident #26 were not able to be located at the facility and were not available in Resident #26'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 medical record review, staff interview, and policy review, the facility failed to ensure preadmission screening and resident reviews (PASARR) were completed accurately and the facility failed to ensure residents were re-screened for Level II services when given a new mental health diagnosis. This affected two (#15 and #57) of three residents reviewed for PASARR. The facility census was 71. Findings include 1. Review of the medical record for Resident #57 revealed an admission date of 06/07/21. Diagnoses included bipolar disorder with psychotic features, schizoaffective disorder, mood disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/26/22, revealed the resident had adequate short and long-term memory and was independent with cognitive skills for daily decision making. The resident was assessed as not having any behaviors. Review of the PASARR dated 06/05/21 revealed section D was checked no for indications of serious mental illness, including…

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, staff interviews, and policy review, the facility failed to ensure care plans were updated timely status post a resident's fall and failed to conduct quarterly care conferences timely. This affected three (#12, #39, and #68) of 24 residents reviewed for care plans. The facility census was 71. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date 08/26/17. Diagnoses included chronic isocheimic heart disease, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, schizoaffective disorder, and anxiety. Review of the medical record revealed Resident #14 enrolled into Hospice services on 11/22/21. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severe cognitive impairment. Resident #14 received Hospice services. Review of the progress notes for Resident #14 dated 05/04/22 and 08/03/22, revealed care conference were conducted with son via phone. The documentation did not support the Hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete discharge summary and recapitulation of stay for residents who discharged from the facility. This affected two (#71 and #73) of three residents reviewed for discharges. The facility census was 71. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/18/22. Diagnoses included wedge compression fracture of second and third lumbar vertebra, anemia, retention of urine, and COVID-19. Resident #71 discharged to the community on 01/18/23. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact. Resident #71 required extensive assist from staff with bed mobility, transfers, dressing, toileting, and personal hygiene. Further review of the medical record for Resident #71 revealed no documentation to support the facility completed a discharge summary or recapitulation of stay upon Resident #71's discharge to community on 01/18/23. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interview, the facility failed to ensure residents that required assistance with activities of daily living (ADL) received adequate assistance with bathing and repositioning. This affected three (#38, #68, and #276) of six residents reviewed for ADLs. The facility identified 69 residents who required assistance with ADLs. The facility census was 71. Findings include: 1. Review of medical record for Resident #68 revealed an admission date of 08/13/22. Diagnoses included stroke with hemiplegia affecting the left non dominant side, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. Resident #68 required extensive one person assistance for bathing. Review of the care plan dated 08/25/22 revealed Resident #68 required assistance with ADLs related to her stroke, blindness, and weakness and required assistance of staff as needed when requested. Review of the December 2022 and January 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 staff interview, observation, record review and policy review, the facility failed to administer medications according to physician orders and failed to initiate treatment orders for wound care. This affected three (Residents #16, #28, and #276) of twenty-four residents reviewed for wound care. The facility census was 71. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 06/09/17. Diagnoses included chronic obstructive pulmonary disease and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the physician orders dated 02/08/20 revealed Resident #16 had an order for Aspercream patch (treats pain): Apply one patch to bilateral shoulders daily in the morning and remove at bedtime. Review of the medication administration record dated January 2023 revealed Resident #16 had received…

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 resident and staff interview, eye center interview, and record review, the facility failed to ensure residents received adequate care to maintain vision. This affected one (Resident #12) of two residents review for vision services. The facility census was 71. Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/20/20. Diagnoses included stage III chronic kidney disease, type I diabetes mellitus, and heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was cognitively intact and did not reject care. Review of the care plan dated 03/25/19 revealed Resident #19 had age-related visual changes which placed her at risk for injury. Interventions included to assist with glasses placement/cleaning, encourage involvement in activities, set up and provide cueing assistance as needed, and vision exams as needed. Review of the medical record revealed Resident #19 received an eye exam on 09/23/22. 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 medical record review, staff interview, and policy review, the facility failed to provide the care and services to prevent a pressure ulcer and the facility failed to initiate physician's orders to treat a pressure ulcer in a timely manner. This affected two (#28 and #70) of five residents reviewed for pressure ulcers. The facility identified nine residents with current pressure ulcers. The facility census was 71. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 08/31/21. Resident #26 began receiving hospice services on 11/22/22. Diagnoses included cerebral infarction, cellulitis of left lower limb, extended spectrum beta lactamase (ESBL) resistance, acute embolism and thrombosis of deep vein of left lower extremity, non-pressure chronic ulcer, type II diabetes mellitus with diabetic dermatitis, and chronic peripheral venous sufficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had severely impaired cognition.…

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, observation, and staff interviews, the facility failed to ensure a fall prevention was in place for a resident at risk for falls. This affected one (Resident #3) of three residents reviewed for falls. The facility census was 71. Findings include: Review of Resident #3's medical record revealed an admission date of 05/01/18. Diagnoses included dementia with behaviors, anxiety, depression, anorexia and non traumatic subarachnoid hemorrhage. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition. Resident #3 required extensive two person assistance for bed mobility and transfers. Review of the care plan, initiated 10/03/18, revealed Resident #3 was at risk for falls related to poor safety awareness, Alzheimer's disease, and a decrease in functional mobility. Interventions included bed in low position (initiated on 03/18/21), a contour mattress and mat beside bed. Observation on 01/23/23 at 3:36 P.M. revealed…

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, observations, resident and staff interview, and policy review, the facility failed to ensure incontinence care was provided timely to residents. This affected two (Residents #4 and #50) of three residents reviewed for incontinent care. The facility census was 71. Findings include: 1. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, chronic back/knee pain, hypertension, hypothyroidism irritable bowel syndrome, anxiety, and left knee pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact and required extensive staff assistance for bed mobility. Resident #4 was dependent on staff for transfers and was incontinent of bladder and bowel. Review of the incontinence care plan, dated 01/19/23, revealed Resident #4 required assistance with activities of daily living (ADL) related to cerebral palsy. The interventions included to check and change 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 observation and staff and resident interview, the facility failed to lighting level was adequate and comfortable in a facility dining room. This had the potential to affect 11 (#10, #13, #17, #21, #23, #26, #36, #50, #48, #50 and #63) residents residing in the red dining room. The facility census was 73. Finding include: Interview on 12/30/19 at 4:34 P.M., revealed Resident #63 reported the lights in the red dining room have been out and been reported in the resident council meetings. Resident #63 reported the facility would always say they would handle it. Resident #63 continued to say when the chandeliers are on it makes the dining room warmer. Resident #63 reported ceiling lights were not working but if working would brighten up the dining room. Observation on 12/30/19 at 4:55 P.M., revealed red dining room had five ceiling lights not working. The chandeliers were positioned about two to three feet away from the residents' head. Chandeliers lights were on low. Residents (#10, #13, #17, #21, #23, #26, #36, #50, #48, #50 and #63) were in the dining room eating dinner.…

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, observations and staff interviews, the facility failed to ensure staff provided a dignified dining experience while feeding cognitive impaired residents. This affected one (Resident #39) out of one reviewed for dignity and respect. The facility census was 73. Findings include: Review of the medical record revealed Resident #39 was admitted on [DATE]. Diagnoses included vascular dementia without behavioral disturbance, major depressive disorder recurrent, dysphagia oral phase, cognitive communication deficit, repeated falls, muscle weakness, unsteadiness on feet, anxiety, hypertension, chronic kidney disease and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/21/19, revealed Resident #39 had severely impaired cognitive deficits, required extensive assistance with activities of daily living, and was frequently incontinent of bladder and bowels. Observations on 12/30/19 at 10:30 A.M., revealed Resident #39 was sitting in the common area with 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 medical record review and facility staff interview the facility failed to accurately code minimum data set (MDS). This affected one (Resident #217) of 22 residents records reviewed during the annual survey. The total facility census was 73. Findings Include: Review of Resident #217's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizo affective disorder depressive type, traumatic brain injury, diabetes mellitus type two, acute osteomyelitis, peripheral vascular disease, and weakness. Review of the admission MDS dated [DATE] revealed the resident was severely cognitively impaired, had no delusions nor hallucinations but had rejection of care one to three days of the review period. The resident was coded as having traumatic brain injury, and psychotic disorder other than schizophrenia. The resident was coded as receiving seven days of antipsychotic medication, seven days antidepressant, and seven days of antibiotics. The resident received four days 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 medical record review and staff interview, the facility failed to ensure a resident's baseline care plan was accurate regarding the resident's skin, safety and elopement risk/interventions. This affected one (#217) of 13 new admission care plans reviewed. The total facility census was 73. Findings include: Review of Resident #217's medical record revealed the resident was admitted to the facility on [DATE] with the diagnosis that include but are not limited to schizo affective disorder depressive type, traumatic brain injury, diabetes mellitus type two, acute osteomyelitis, peripheral vascular disease, and weakness. Review of Resident #217's progress note revealed on 12/12/19 at 3:15 P.M. the resident had an admission note that revealed the resident assessment was completed and resident was alert and forgetful, unable to read with garbled speech intermittently. Resident blood sugar was 169, with no signs of hyperglycemia. Skin was assessed with left large toe posterior open wound one by one inch open…

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, observation, and resident and staff interview the facility failed to ensure dependent residents were provided shaving assistance. This affected one (Resident #10) of four reviewed for activities of daily living (ADL). The total facility census was 73. Findings include: Review of Resident #10's medical record revealed an admission date of 09/19/19. Diagnoses included dementia, schizoaffective disorder, muscle weakness, convulsions, anxiety disorder, hyperlipidemia, Alzheimer's disease, hypertension, osteoarthritis and benign prostatic hyperplasia without lower urinary tract symptoms. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was severely impaired and required extensive assist of two for bed mobility and transfers. He was totally dependent for toileting, eating, personal hygiene and dressing. Resident #10 had unclear speech and rarely makes self-understood. Review of the plan of care dated 10/09/19 revealed Resident #10 had self-care impairment 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 medical record review, observations and staff and resident interview, the facility failed to provide a resident with activities in accordance with the resident's preferences including providing a newly admitted resident with an activity calendar identifying activities provided by the facility. This affected one (#120) of one reviewed for activities. The total facility census was 73. Findings include: Review of Resident #120's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include hip surgery, hypertension, chronic kidney disease, history of cancer and obesity. The resident is noted to be alert and oriented and able to make needs known. Review of the residents' activities admission assessment revealed the assessment was put in the computer on 12/31/19. Resident #120's likes are listed as read books on her tablet, is interested in the senior center, no interest in crafts, likes hallmark channel and smooth jazz. Enjoys outings with friends and families, euchre, games…

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, observation, and resident and staff interviews the facility failed to provide ordered skin care. This affected one (Resident #12) of one resident reviewed for non pressure skin alteration. The total facility census was 73. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included but are not limited to diabetes type two, weakness, cellulitis of right lower limb, cellulitis of left lower limb, urinary tract infection lymphedema, multiple sclerosis and obesity. Review of the 10/01/19 quarterly minimum data set revealed the resident was cognitively intact, had no behaviors delusions or hallucinations or rejection of care. The resident required extensive assistance with bed mobility, dressing, toileting and personal hygiene, and was dependent on staff for transfers. Review of care plans revealed the resident had altered skin integrity non pressure related to moisture associated skin dermatitis (MASD) to bilateral…

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, hospital record review, facility staff and physician interview and review of Self Reported Incident (SRI) the facility failed to meet the behavioral health needs of residents. This affected one (Resident #217) of two reviewed for behavioral emotional services. The total facility census was 73. Findings include: Review of Resident #217's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizo affective disorder depressive type, traumatic brain injury,diabetes mellitus type two, acute osteomyelitis, peripheral vascular disease, and weakness. Review of the admission minimum data set (MDS) dated [DATE] revealed the resident was severely cognitively impaired, had no delusions or hallucinations but had rejection of care one to three days of the review period. The resident was coded as having traumatic brain injury, and psychotic disorder other than schizophrenia. The resident was coded as receiving seven days of antipsychotic 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 medical record review, hospital record review, and facility staff interview the facility failed to ensure medication irregularities were identified by the pharmacist. This affected one (Resident #217) of six reviewed for unnecessary medications. The facility census was 73. Findings include: Review of Resident #217's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis included schizo affective disorder depressive type, traumatic brain injury, diabetes mellitus type two, acute osteomyelitis, peripheral vascular disease, and weakness. Review of the admission Minimum Data Set, dated [DATE] revealed the resident was severely cognitively impaired, had no delusions, hallucinations but had rejection of care one to three days of the review period. The resident was coded as having traumatic brain injury, and psychotic disorder other than schizophrenia. The resident was coded as receiving seven days of antipsychotic medication, seven days antidepressant, and seven days 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, hospital record reveiw and facility staff interview the facility failed to ensure residents received medications as ordered. This affected Resident #217 who had orders for an antiphyscotic upon dischage from the hospital. The order was not followed up on and the resident was not adminsiterd the mediation while at the facility for eight days. This affected one (Resident #217) of two reviewed for behavioral emotional services. The total facility census was 73. Findings Include: Review of Resident #217's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizo affective disorder depressive type, traumatic brain injury,diabetes mellitus type two, acute osteomyelitis, peripheral vascular disease, and weakness. Review of the admission minimum data set (MDS) dated [DATE] revealed the resident was severely cognitively impaired, had no delusions or hallucinations but had rejection of care one to three days of the review period. The resident was coded…

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, staff interview and facility policy review, the facility failed to ensure medications were not expired. The facility identified two residents (#52 and #54) who had orders for Vitamin D and lived on the 300 unit, there were no residents identified who received Aspirin 325 milligrams (mg). The facility census was 73. Findings include: Observation on [DATE] at 11:17 A.M. of the blue medication storage room revealed nine bottles of enteric coated Aspirin 325 mg with 100 tablets. Each bottle had an expiration date of 07/2019. There were also two bottles of Vitamin D 400 International Units (IU) with 100 tablets. Each bottle had an expiration date of 11/2019. Interview at the time of the observation with Corporate Clinical Nurse #700 verified the nine bottles of enteric coated aspirin and two bottles of Vitamin D were all expired and should have been removed from the medication storage room and discarded. Review of the facility policy titled Medication Storage, Storage of Medication, 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.