Harmony Court Rehab And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure physician visits were signed and dated in a timely manner. This affected two Residents (#01, #12) out of two residents reviewed. The facility census was 106. 1) Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. Diagnoses included abscess of right foot, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability (ID), essential primary hypotension, and diabetes mellitus (DM). The resident was housed in the secured Memory Care Unit (MCU) and had a guardian related to mental disability. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 was cognitively intact. The resident was independent or required minimal assistance with activities of daily living (ADL). Review of the Nurse Practitioner (NP) progress note for Resident #01 recorded as a late entry for 01/28/26 at 5:42 P.M. and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure medications were given as prescribed. This affected one (#15) of four residents reviewed for medication administration. The facility census was 107.Findings include:Review of the medical record for Resident #15 revealed an admission date of 5/30/25. The resident was admitted with diagnoses including schizoaffective disorder, Chronic Obstructive Pulmonary Disease (COPD), major depressive disorder and syndrome of inappropriate secretion of anti-diuretic hormone.The quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required supervision with eating, bed mobility, toileting hygiene and transfers.Observation on 10/29/25 at 10:19 A.M. of the medication pass with Registered Nurse (RN) #100 for Resident #15 revealed he prepared Fluphenazine (antipsychotic) one 10 milligram (mg) tablet (tab), Hydroxyzine Pamoate (antihistamine) 25 mg, Metoprolol (high blood pressure) 25 mg tab, Lamotrigine (Bipolar…

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 reviews, observations and staff interviews the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 27 opportunities observed which resulted in an 11.11 percent (%) error rate. This affected one (#15) of four residents reviewed for medication administration. The facility census was 107.Findings include:Review of the medical record for Resident #15 revealed admission date of 5/30/25. The resident was admitted with diagnoses including schizoaffective disorder, Chronic Obstructive Pulmonary Disease (COPD), major depressive disorder and syndrome of inappropriate secretion of anti-diuretic hormone.The quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required supervision with eating, bed mobility, toileting hygiene and transfers.Review of the medical record for Resident #15 revealed a physician order dated 08/19/25 for Fluphenazine Hydrochloride (schizoaffective disorder) 10 milligram (mg) give two…

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 review the facility policy, the facility failed to ensure proper storage of medication. This had the ability to affect all 25 residents on the hall. The facility census was 107.Findings include:Observation on 10/29/25 at 10:09 A.M. of the medication pass revealed RN#100 prepared medication for Resident #14 removed the medication cup from the cart, turned in the opposite direction, walked approximately five feet down the hall and entered Resident #14's room. The unattended medication cart was left unlocked in the hall for approximately four minutes.Interview on 10/29/25 at 10:09 A.M. with RN #100 acknowledged the medication cart should not be left unlocked if unattended. RN #100 verified he he did not lock the medication cart and left it unsecured in the hallway. Review of the facility policy, Medication storage in the facility dated 11/11 revealed medications should be stored safety and securely.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and Centers for Disease Control and Prevention guidelines the facility failed to ensure proper infection control measures were followed during medication administration. This had the potential to affect one Resident (#14) of four reviewed. The facility census was 107.Findings include:Review of medical record for Resident #14 revealed admission date of 12/13/17. The resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), hemiplegia, bipolar disorder and depression. The annual Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition and he required supervision with eating, bed mobility, toileting hygiene and transfers.Observation on 10/29/25 at 9:58 A.M. of the medication pass with Registered Nurse (RN) #100 for Resident #14 revealed RN #100 unlocked the medication cart and removed the medication card from the drawer of the cart. He was observed punching 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 medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to ensure residents were free from verbal abuse by the staff. This affected one (Resident #104) of three residents reviewed for abuse. The facility census was 112 residents. Findings include: Review of the medical record for Resident #104 revealed an admission date of 02/13/25 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, bipolar disorder, post-traumatic stress disorder, and aphasia. Review of the facility SRI for Resident #104 initiated 04/19/25 revealed the facility substantiated an allegation of abuse per Licensed Practical Nurse (LPN) #500 towards Resident #104. On 04/19/25 at approximately 5:30 P.M. Resident #104 and another nurse witnessed LPN #500 using profane language and speaking in a verbally abusive manner towards the resident. The facility reported LPN #500's actions to the Ohio Board of Nursing (OBN) and terminated the nurse. Review of the 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.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to prevent resident elopements. This affected one (Resident #45) of three residents reviewed for elopements. The facility census was 112 residents. Findings include: Review of the medical record for Resident #45 revealed an admission date of 11/20/23 with diagnoses including atherosclerotic heart disease, Alzheimer's disease, psychotic disorder with delusions and hallucinations, and Parkinson's disease. Review of the elopement risk assessment for Resident #45 dated 01/23/25 revealed the resident was at risk for elopement due to a history of wandering with a pattern, goal-directed wandering, and wandering that might affect the resident's safety and the privacy of others. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 03/28/25 revealed the resident was moderately cognitively impaired, was independently mobile with a walker, and required supervision with activities of daily living (ADLs). Review of the 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) prior to provision of care for residents on enhanced barrier precautions (EBP.) This affected two (Residents #11 and #13) of three residents reviewed. The facility census was 107 residents. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 02/27/23 with diagnoses including hypotension, gastrotomy, colostomy, obesity, and dysphagia. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 12/07/24 revealed the resident had mild cognitive deficits and required substantial to total dependence with activities of daily living (ADLs.) Review of care plan for Resident #13 dated 09/23/24 revealed the resident required EBP related to an indwelling medical device (colostomy) regardless of multi drug resistant organisms (MDROs). Interventions included staff should don gowns and gloves prior to and during high-contact resident care activities that…

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 facility Self-Reported Incident Reviews (SRIs), staff interview, and review of the facility policy, the facility failed to ensure allegations of misappropriation were reported in a timely manner to the Ohio Department of Health (ODH). This affected one (Residents #12) of 12 residents reviewed for misappropriation. The facility census was 110 residents. Findings include: Review of the facility SRI initiated 09/30/24 revealed the facility substantiated an allegation of misappropriation of Resident #12's narcotic medication, oxycodone per Registered Nurse (RN) #175. The facility substantiated misappropriation had occurred and RN #175 was terminated. Interview on 10/30/24 at 9:00 A.M. with the Director of Nursing (DON) confirmed she received a text from Licensed Practical Nurse (LPN) #225 on Friday 09/27/24 at 6:45 P.M. with a photograph of a Resident #12's controlled substance record with Registered Nurse (RN) #175's initials signing out doses of medication but on some of the lines Resident #19's name was written in the margin. The DON confirmed she attempted to call…

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 Self-Reported Incident Reviews (SRIs) staff interview, and review of the facility policy, the facility failed to conduct a thorough investigation of misappropriation of resident medications and failed to protect residents during the investigation. This affected one (Residents #12) of 12 residents reviewed for misappropriation and had the potential to affect all of the residents residing in the facility. The facility census was 110 residents. Findings include: Review of the facility SRI initiated 09/30/24 revealed the facility substantiated an allegation of misappropriation of Resident #12's narcotic medication, oxycodone per Registered Nurse (RN) #175. The facility substantiated misappropriation had occurred and RN #175 was terminated. Interview on 10/30/24 at 9:00 A.M. with the Director of Nursing (DON) confirmed she received a text from Licensed Practical Nurse (LPN) #225 on Friday 09/27/24 at 6:45 P.M. with a photograph of a Resident #12's controlled substance record with Registered Nurse (RN) #175's initials signing out doses of medication but on some 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.

Based on medical record review, observation, and staff interview the facility failed to ensure residents' toilets were functioning properly. This affected two (Residents #58 and #63) of two residents reviewed for physical environment. The facility census was 102 residents. Findings include: 1. Review of the medical record for Resident #63 revealed an admission date of 01/24/23 with diagnoses including Alzheimer's disease with late onset and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment for Resident #63 dated 12/26/23 revealed the resident had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs). Observation on 01/30/24 at 12:45 P.M. of Resident #63's bathroom revealed the bathroom floor was covered with water and pieces of toilet paper and paper towels. A large piece of clear plastic was on the bathroom floor beside the bathroom door which had been used to cover the toilet. The toilet was out of order and did not flush properly. Interviews on 01/30/24 at 12:55 P.M. with Licensed Practical Nurse (LPN) #163 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 review of the facility policy, the facility failed to ensure the water temperature in residents' rooms was within safe temperature limits to prevent possible scalding injuries. This affected two (Residents #35 and #38) of two residents reviewed for physical environment. The facility census was 102 residents. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 01/17/24 with diagnoses including schizoaffective disorder bipolar type, anxiety disorder, blindness of right eye and low vision of left eye. Review of the Minimum Data Set (MDS) assessment for Resident #35 dated 01/21/24 revealed the resident had moderate cognitive impairment and required supervision and verbal cues for all activities of daily living (ADLs). Observation on 01/30/24 at 2:03 P.M. with Maintenance Director (MD) #210 revealed the water temperature of the Residents #35's bathroom sink was 127 degrees Fahrenheit (F.) Interview on 01/30/24 at 2:15 P.M. with MD #210 confirmed the water temperature for Resident #35'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.

Based on observation, review of a food menu, review of a food substitution log, staff interview, and policy review, the facility failed to ensure approved menus were followed. This affected all residents except seven (#43, #75, #77, #96, #353, #354, and #359) residents that received no food by mouth. The facility census was 108. Findings include: Review of the facility's menu for 12/06/23 revealed regular diets were to receive three (3) ounces (oz) of barbeque chicken, four (4) oz of macaroni and cheese, 4 oz of baked beans, one square of cornbread, and 4 oz of seasoned fruit. Mechanical diets were to receive 3 oz of ground barbeque chicken, 4 oz of macaroni and cheese, 4 oz of mashed baked beans, one square of cornbread, and one piece of fresh banana. Pureed diets were to receive 3 oz of pureed barbeque chicken, 4 oz of pureed macaroni and cheese, 4 oz of pureed baked beans, two (2) oz of pureed bread, and 4 oz of puree banana. Review of the facility's undated substitution log revealed potatoes were substituted instead of macaroni and cheese and vegetables were used as a substitute…

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, review of a facility provided list of residents by diet type, and policy review, the facility failed to ensure the kitchen and equipment were clean and sanitary, and resident food and drink items were stored in a manner to prevent spoilage. This affected all resident with the exception of seven (#43, #75, #77, #96, #353, #354, and #359) residents identified by the facility that received no food by mouth. The facility census was 108. Findings include: 1. Observation of the facility's kitchen on 12/04/23 at 10:29 A.M. revealed yellow debris on the top of the dishwasher, a pink substance on the ledge of the ice machine that came off on a paper towel when Dietary Supervisor (DS) #80 wiped the ledge, a black substance built up around the rim of the ice cream cooler that came off on a paper towel when DS #80 wiped the ledge, and a brown and black substance on the floor below the preparation sink. There was also an area in the ceiling that appeared to have paint film hanging down above the plate storage cart. Interview with DS #80 on 12/04/23 at 10:29…

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, staff interview, review of water management logs, review of infection control logs, review of staff personnel files, review of a water management plan, and review of facility policies, the facility failed to ensure newly hired employees and residents admitted to the facility were timely screened for tuberculosis, failed to ensure resident personal use items were clean and sanitary, failed to ensure testing measures were maintained to prevent bacteria growth in the water system, failed to adequately track resident infections, and failed to maintain proper infection control measures when performing resident care. This directly affected Resident #96 observed during tracheostomy care, Resident #355 observed with an unsanitary personal fan in use, three (#02, #83, and #90) of five residents reviewed for tuberculosis screening, and one (State Tested Nurse Aide #15) of five newly hired staff members at the facility. Additionally, the failure to maintain a program to prevent and monitor for bacteria growth in the water system, and a system 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.

Review of record review, staff interviews, and facility policy reviews, the facility failed to implement the antibiotic stewardship program routinely to ensure infections and antibiotics were monitored. This had the potential to affect all 108 residents in the facility. Findings include: Interview on 12/12/23 at 10:23 A.M. with Licensed Practical Nurse Infection Control (LPNIC) #131 stated the facility didn't monitor any residents who utilized antibiotics four months, which included April 2023, May 2023, June 2023, and July 2023. LPNIC #131 stated she was hired in August 2023, and she started the monitoring of residents who were on antibiotics in August 2023. Interview on 12/12/23 at 1:00 P.M. with the Director of Nursing (DON) verified the facility was not monitoring the antibiotic stewardship and residents with infections from 04/2023 through 07/31/23. Review of the facility's records dated from 04/01/23 through 07/31/23 revealed there was no documentation supplied by the facility that showed that infections and antibiotics used by residents were being followed. 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.

Based on observation, record review and staff interview, the facility failed to ensure residents were not served meals in disposable Styrofoam food boxes. This affected 11 (Residents #12, #18, #20, #32, #47, #54, #76, #84, #89, #93 and #303) of 11 observed for meal services. Additionally, the facility failed to ensure a resident's urinary catheter bag was covered for dignity. This affected one (Resident #361) of one resident observed for catheter bag coverage. The facility census was 108. Findings include: 1. Observation of tray line in the kitchen on 12/06/23 at 11:41 A.M. revealed Dietary [NAME] #64 served lunch to Residents #12, #18, #20, #32, #47, #54, #76, #84, #89, #93 and #303 in disposable Styrofoam food boxes. During an interview on 12/06/23 at 11:41 A.M., Dietary [NAME] #64 and Dietary Supervisor #80 revealed the kitchen was out of plate covers and had to serve Residents #12, #18, #20, #32, #47, #54, #76, #84, #89, #93 and #303 lunch in disposable Styrofoam food boxes. 2. Review of the medical record for Resident #361 revealed an admission date on 11/29/23. Diagnoses…

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, review of a food recipe, and review of a facility list of residents by diet type, the facility failed to ensure pureed food items were prepared following an approved recipe to conserve the nutritional value. This affected five (#19, #31, #34, #44, and #98) of five residents identified by the facility that receive pureed diets. The facility census was 108. Findings include: Review of the recipe for seasoned green beans, dated 11/22/15, revealed staff should remove the desired number of servings and add nutritive liquid, milk, or broth and blend until the desired consistency for pureed diets. Further review revealed approved thickener could be added to achieve the desired consistency. Observation of the kitchen on 12/06/23 at 11:41 A.M. revealed the pureed green beans appeared thick and light green in color with streaks of dark green throughout the food. Interview with [NAME] #64 on 12/06/23 at 11:41 A.M. revealed the pureed green beans were mixed with mashed potatoes. [NAME] #64 stated the facility was out of thickener and she added the mashed…

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

Based on observation, record review, and staff interview, the facility failed to ensure the kitchen hood was maintained in a safe condition. This affected all residents except seven residents (#43, #75, #77, #96, #353, #354, and #359) who received no food by mouth. The facility census was 108. Findings include: Observation of the facility's kitchen on 12/04/23 at 10:29 A.M. revealed metal pieces of the kitchen hood appeared to be flaking off above the stove. Interview with Dietary Supervisor #80 on 12/04/23 at 10:29 A.M. verified metal pieces of the kitchen hood appeared to be flaking off above the stove.

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 call light was within reach and a resident's privacy curtain were in good repair. This affected two (#42 and #62) residents out of 35 residents reviewed for call lights. The facility census was 108. Findings include: 1. Review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required one-person extensive assistance with transfers, dressing, toileting, and bathing. Resident #62 also required supervision with eating. Review of Resident #62's care plan dated 08/03/23 revealed interventions in place for falls including the call light should be kept accessible. Observation on 12/05/23 at 9:17 A.M. revealed Resident #62's call…

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 a resident's code status was accurate in the medical record. This affected one (Resident #62) of one reviewed for advanced directives. The facility census was 108. Findings include: Review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required one-person extensive assistance with transfers, dressing, toileting, and bathing. Resident #62 also required supervision with eating. Review of the care plan dated 04/17/23 revealed Resident #62 had chosen to be a full code. Interventions included complete and update advanced directives document and for staff to review advanced directives on file. Review of the physician order dated 04/17/23 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 interview, the facility failed to ensure a resident's family member was made aware of an injury the resident incurred. The facility also failed to ensure the resident's primary care physician was consulted when the resident had a change of condition. This affected one (Resident #87) of one reviewed for notification. The facility census was 108. Findings include: Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance, protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred to the hospital on [DATE] at 5:30 P.M. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe cognitive impairment and at that time she was assessed as not having pain. She was noted as being under hospice care. Review of Resident #87's facesheet revealed her son was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure residents were given a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) when being cut from skilled services and remaining in the facility. This affected two (Residents #154 and #155) of three residents reviewed for beneficiary notices. The facility census was 108. Findings included: 1. Review of the clinical record revealed Resident #154 was admitted to the facility on [DATE] and discharged on 10/18/23. His diagnoses included type II diabetes with foot ulcer, hypertensive chronic kidney disease, end stage renal disease, hypertension secondary to endocrine disorders, atherosclerotic heart disease of the native coronary artery, diabetic polyneuropathy, chest pain, and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #154's Brief Interview for Mental Status…

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 walls were free from patches and a resident's vent and ceiling were free of debris. This affected three (Resident #16, #60, and #69) residents of three residents reviewed for environment. The facility census was 108. Findings include: 1. Review of the Resident #69's medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease unspecified, respiratory disorders in diseases classified elsewhere, type two diabetes mellitus, Alzheimer's disease with early onset and adult failure to thrive. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required set up assistance with bathing and was independent with all other activities of daily living (ADLs). Observation of Resident #69's room on 12/04/23 at 12:25 P.M. revealed several large patches on his wall including 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.

Based on record review, interview, observation, and facility policy review, the facility failed to ensure a resident was free from restraints. This affected one (Resident #355) of one resident reviewed for the use of restraints. The facility census was 108. Findings include: Review of the medical record for Resident #355 revealed an admission date 12/01/23. Diagnoses included cerebral infarction, chronic respiratory failure, tracheostomy, gastric tube, fracture of part of body of right mandible, cocaine abuse, and psychoactive substance abuse. Review of the baseline care plan dated 12/01/23 revealed no interventions in place for the use of a restraint to Resident #355's right hand. Further review of the medical record from 12/01/23 through 12/03/23 revealed no assessments for the use of restraints/mitt to the resident's right hand. Review of Resident #355's physician orders revealed no orders for restraint use or monitoring. Review of the physician order dated 12/04/23 revealed an order to discontinue the hand mitt. Review of the health status note dated 12/02/23, documented by…

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, interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure an allegation of misappropriation and an allegation of injury of unknown origin were reported to the state agency. This affected two (Residents #69 and #87) of two residents reviewed for abuse. The facility census was 108. Findings include: 1. Review of the Resident #69's chart revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with early onset, and adult failure to thrive. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required set up assistance with bathing and was independent with all other activities of daily living (ADLs). Interview with Resident #69 on 12/04/23 at 12:25 P.M. revealed Resident #69's sister stole 6500 dollars from him by taking out 500 dollars a day 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, interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure an allegation of misappropriation and an allegation of injury of unknown origin were thoroughly investigated. This affected two (Residents #69 and #87) of two residents reviewed for abuse. The facility census was 108. Findings include: 1. Review of the Resident #69's chart revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with early onset, and adult failure to thrive. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required set up assistance with bathing and was independent with all other activities of daily living (ADLs). Interview with Resident #69 on 12/04/23 at 12:25 P.M. revealed Resident #69's sister stole 6500 dollars from him by taking out 500 dollars a day 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 observation, record review and interview, the facility failed to ensure a resident's dental status was accurately coded on the Minimum Data Set (MDS) assessment. This affected one (Resident #38)of one resident reviewed for accuracy of resident assessments. The facility census was 108. Findings include: 1. Review Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, other low back pain, phantom limb syndrome with pain, acquired absence of left leg above knee, bipolar disorder, major depressive disorder, heart failure, type two diabetes mellitus without complications, unspecified convulsions, and muscle weakness. Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident #38 was independent with eating and required limited assistance with transfers. Personal hygiene only occurred…

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 addressed a resident's risk for skin impairment. This affected one (Resident #62) of three residents reviewed for care planning. The facility census was 108. Findings include: Review of the medical record for Resident #62 revealed an admission date of 04/14/23. Diagnoses included hemiplegia and hemiparesis, major depressive disorder, dementia, dependence on wheelchair, and cognitive deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 required extensive one-person physical assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the admission skin assessment dated [DATE] revealed Resident #62 had skin issues including a skin tear. Review of the weekly skin assessment dated [DATE] revealed Resident #62 had a stage one pressure ulcer tot he left heel measuring 3.0 centimeters (cm) by 3.0 cm…

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 ensure care plans reflected the resident's current status. This affected two (Residents #57 and #42) of five residents reviewed for care planning. The facility census was 108. Findings include: 1. Review of Resident #57's clinical record revealed an admission date of 05/09/23. Diagnoses included hydronephrosis with renal and ureteral calculous obstruction, liver cell carcinoma, type II diabetes, and gastritis. Review of Resident #57's quarterly Minimum Data Set (MDS) assessment completed on 11/03/23 revealed she was cognitively intact. The assessment revealed she was on insulin seven days during the look back period and was receiving the following medication: an antianxiety, antidepressant, anticoagulant, antibiotic, and a hypoglycemic. Review of Resident #57's physician orders revealed she was prescribed Docusate Sodium Capsule 100 milligrams (mg) to give one capsule by mouth two times a day for constipation, MiraLax Powder (Polyethylene Glycol…

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 comprehensive care plan was updated to reflect a resident's risk for skin impairment. This affected one (Resident #62) of three residents reviewed for care planning. The facility census was 108. Findings inlcude: Review of the medical record for Resident #62 revealed an admission date of 04/14/23. Diagnoses included hemiplegia and hemiparesis, major depressive disorder, dementia, dependence on wheelchair, and cognitive deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 required extensive one-person physical assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the admission skin assessment dated [DATE] revealed Resident #62 had skin issues including a skin tear. Review of the weekly skin assessment dated [DATE] revealed Resident #62 had a stage one pressure ulcer tot he left heel measuring 3.0 centimeters (cm) by…

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 received routine nail care and assistance with grooming. This affected three (#38, #49 and #62) residents out of six residents reviewed for activities of daily living (ADL) care. The facility census was 108. Findings include: 1. Review of the Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, other low back pain, phantom limb syndrome with pain, acquired absence of left leg above knee, bipolar disorder, major depressive disorder, heart failure, type two diabetes mellitus without complications, unspecified convulsions, and muscle weakness. Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident #38 was independent with eating and required limited assistance with transfers. Personal hygiene…

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, staff interview, and review of facility policy, the facility failed to reposition and check dependent residents to see if they needed incontinence care in a timely manner. This affected two (Residents #77 and #96) of two residents reviewed for repositioning. The facility census was 108. Findings include: 1. Review of the medical record for Resident #77 revealed an admission date of 12/23/21. Diagnoses included anoxic brain damage, epilepsy, tracheostomy, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was severely cognitively impaired. The resident was totally dependent upon staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the plan of care dated 10/14/23 revealed Resident #77 was at risk for incontinence with interventions including the use of a condom catheter, providing incontinence care every two hours, and as needed, keep call light within reach, monitor of signs…

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 received routine podiatry care. This affected one (Resident #38) of one resident reviewed for podiatry services. The facility census was 108. Findings include: Review of the Resident #38's chart revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, other low back pain, phantom limb syndrome with pain, acquired absence of left leg above knee, bipolar disorder, major depressive disorder, heart failure, type two diabetes mellitus without complications, unspecified convulsions, and muscle weakness. Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident #38 was independent with eating and required limited assistance with transfers. Personal hygiene only occurred once or twice during the assessment period. 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for two residents (#2 and #14) of two residents reviewed for falls. Facility census was 108. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 04/11/23. Diagnoses included chronic kidney disease, vascular dementia, and epilepsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively impaired. Resident #14 was dependent upon staff for Activities of Daily Living (ADLs) and utilized a wheelchair. Review of the plan of care dated 11/02/23 revealed Resident #14 was at risk for falls. Interventions included anticipate and meet resident's needs, educate the resident and family about safety, encourage to wear nonskid footwear, follow facility fall protocol, keep the call light accessible, and give reacher to allow resident to pick up objects. Observation on 12/13/23 at 2:10…

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 medical record, observation, interview, and facility policy, the facility failed to provide safe positioning of a urinary Foley catheter bag. This affected one (Resident #355) of two residents reviewed for positioning of a catheter bag. The facility census was 108. Findings include: 1. Review of the medical record for Resident #355 revealed an admission date 12/01/23. Diagnoses included cerebral infarction, chronic respiratory failure, tracheostomy, gastric tube, fracture of part of body of right mandible, cocaine abuse, and psychoactive substance abuse. Interview and observation on 12/04/23 at 12:28 P.M. with Licensed Practical Nurse (LPN) #101 revealed Resident #335's catheter bag was lying flat on the floor at the foot of the bed. Interview and observation on 12/04/23 at 3:50 P.M. with the Director of Nursing (DON) revealed Resident #355's catheter bag was on the floor at the foot of the bed. Interview on 12/06/23 at 6:30 A.M. with the DON revealed Resident #355's catheter was discontinued because there was no reason for him to have the catheter. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy review, the facility failed to administer supplemental tube feeding as ordered. This affected one (#43) of three residents reviewed for tube feedings. The facility census was 108. Findings included: Review of the medical record for Resident #43 revealed an admission date 11/07/23. Diagnoses included end stage renal disease, dependence on renal dialysis, anemia, gastrostomy status, dysphagia, and tracheostomy status. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was assessed as severely cognitively impaired. Resident #43 was dependent for toileting, dressing, putting on and and taking off footwear, and oral care. Review of a plan of care dated 11/07/23 revealed Resident #43 required tube feeding related to dysphagia. Interventions included the resident needed the head of bed elevated 45 degrees during and thirty minutes after tube feed, discuss with the resident and family any concerns about tube…

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, resident and staff interview, and facility policy review, the facility failed to ensure a resident's oxygen tubing was dated and changed timely, and failed to ensure oxygen tubing was appropriately connected to the concentrator. This affected two (#49 and #69) of two residents reviewed for oxygen therapy. The facility census was 108. Findings include: 1. Review of Resident #69's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including unspecified chronic obstructive pulmonary disease, respiratory disorders in diseases classified elsewhere, type two diabetes mellitus, Alzheimer's disease with early onset, and adult failure to thrive. Review of Resident #69's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, required set up assistance with bathing, and was independent with all other activities of daily living (ADLs). Resident #69 was on oxygen therapy. Observation of 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, medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure residents were provided interventions for pain management in a timely manner. This affected one (#87) of 32 residents reviewed for pain control. The facility census was 108. Findings included: Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance, protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred to the hospital on [DATE] at 5:30 P.M. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment and was assessed to have no pain. Resident #87 was noted as being under hospice care. Review of Resident #87's care plan dated 03/21/23 revealed the resident had the potential for pain with a goal to be free of…

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

Based on personnel file review, staff interview, and policy review, the facility failed to ensure state tested nurse aides (STNAs) received performance evaluations at least every 12 months. This affected two (#03 and #24) of two STNA personnel files reviewed for performance evaluations. The facility census was 108. Findings include: 1. Review of STNA #24's personnel file revealed STNA #24 was hired at the facility on 06/14/00. Further review of STNA #24's personnel file revealed STNA #24 did not receive an annual evaluation from 06/14/22 to 06/14/23. Interview on 12/11/23 at 10:17 A.M., with Human Resource #90 verified STNA #24 did not receive an annual evaluation from 06/14/22 to 06/14/23. 2. Review of STNA #03's personnel file revealed STNA #03 was hired at the facility on 03/04/09. Further review of STNA #03's personnel file revealed STNA #03 did not receive an annual evaluation from 03/04/22 to 03/04/23. Interview on 12/11/23 at 10:17 A.M., with Human Resource #90 verified STNA #03 did not receive an annual evaluation from 03/04/22 to 03/04/23. Review of the facility's undated…

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 pharmacy recommendations and irregularities were addressed by the physician in a timely manner. This affected two (#09 and 57) of five residents reviewed for unnecessary medications. The facility census was 108. Findings include: 1. Review of Resident #09's chart revealed the resident admitted to the facility on [DATE]. Diagnoses included psychotic disorder with hallucinations due to known physiological condition, obsessive compulsive disorder, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity with agitation, and anxiety disorder. Review of Resident #09's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive assistance with bed mobility, dressing, and toileting. Resident #09 required total dependence with transfers and personal hygiene, and supervision with eating. Review of Resident #09'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 gradual dose reductions were attempted in a timely manner and failed to ensure residents had appropriate indications for use of antipsychotic medications. This affected two (#09 and #42) of five residents reviewed for unnecessary medications. The facility census was 108. Findings include: 1. Review of Resident #09's chart revealed the resident admitted to the facility on [DATE]. Diagnoses included psychotic disorder with hallucinations due to known physiological condition, obsessive compulsive disorder, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity with agitation, and anxiety disorder. Review of Resident #09's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive assistance with bed mobility, dressing, and toileting. Resident #09 required total dependence with transfers and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to timely administered medications as ordered resulting in a medication error rate greater than five percent (%). There were two medication errors observed out of 27 opportunities for a medication error rate of 7.4%. This affected one (#98) of five residents observed during medication administration. The census was 108. Findings included: Review of the medical record for Resident #98 revealed an admission date 08/25/23. Diagnoses included human immunodeficiency virus (HIV) disease, respiratory failure, feeding difficulties, and major depressive disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #98 had a Brief Interview Mental Status of 09 that indicated the resident was moderately cognitively impaired. Resident #98 required extensive one-person physical assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. Review of a plan of care dated 12/01/23…

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, staff interview, and review of a facility policy, the facility failed to administer medications as ordered by the physician resulting in significant medication errors. This affected two (#42 and #98) out of five residents reviewed for medications. The facility census was 108. Findings included: 1. Review of the medical record for Resident #98 revealed an admission date 08/25/23. Diagnoses included human immunodeficiency virus (HIV) disease, respiratory failure, feeding difficulties, and major depressive disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #98 had a Brief Interview Mental Status of 09 that indicated the resident was moderately cognitively impaired. Resident #98 required extensive one-person physical assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. Review of a plan of care dated 12/01/23 revealed Resident #98 had HIV/AIDS (Acquired Immunodeficiency Syndrome) and was at risk for rapid physical or…

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, resident and staff interview, and review of facility policy, the facility failed to ensure a resident received routine dental care. This affected one (#38) of two residents reviewed for dental services. The facility census was 108. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, other low back pain, phantom limb syndrome with pain, acquired absence of the left leg above the knee, bipolar disorder, major depressive disorder, heart failure, type two diabetes mellitus without complications, unspecified convulsions, and muscle weakness. Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Resident #38 was independent with eating and required limited assistance with transfers. Further review of the MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure medications administered to residents were accurately documented in the medical record. This affected one (#87) out of 32 residents reviewed for medical record documentation. The facility census was 108. Findings included: Review of the medical record for Resident #87 revealed an admission date of 01/24/23 with diagnoses including Alzheimer's disease with late onset, muscle weakness, dementia without behavioral disturbance, protein-calorie malnutrition, adult failure to thrive, anorexia, and osteoarthritis. Resident #87 was transferred to the hospital on [DATE] at 5:30 P.M. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was assessed with severe cognitive impairment and was assessed as not having pain. The resident was noted as being under hospice care. Review of Resident #87's narcotic count sheet for the pain medication Norco 5-325 milligrams (mg) to give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and resident and staff interviews, the facility failed to ensure resident call lights were in working order. This affected three (#38, #60, and #69) of 35 residents reviewed for call lights. The facility census was 108. Findings include: 1. Review of Resident #38's medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, other low back pain, acquired absence of left leg above knee, bipolar disorder, and muscle weakness. Review of Resident #38's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, and toileting. Observation of Resident #38's room on 12/05/23 at 9:27 A.M. revealed Resident #38's call light was not functioning or turning on in the room, hallway, or nursing station. Interview with Resident #38 on 12/05/23 at 9:27 A.M. revealed her call light had not worked for a couple of days. 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.

Based on record review, review of the facility policy, and staff interview, the facility failed to the facility failed to ensure a state tested nurse aide (STNA) received a minimum of 12 hours of in services or training per year. This affected one of two STNAs reviewed for STNA in services. This had the potential to affect all 108 residents residing in the facility. Findings include: Review of State Tested Nurse Aide (STNA) #24's personnel file revealed STNA #24 was hired at the facility on 06/14/2000. Further review of STNA #24's personnel file revealed STNA #24 did not receive any in services or training from 06/14/22 to 06/14/23. Interview on 12/11/23 at 10:17 A.M. with Human Resource #90 verified STNA #24 did not receive any in services or training from 06/14/22 to 06/14/23. Review of the facility's undated personnel policy revealed STNAs are required to complete twelve hours of in services per calendar year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility initiated transfer notification, and staff interview, the facility failed to provide each resident with a notice before transfer/discharge that include all information required in the contents of the notice. This affected four residents (#13, #21, #73, and #92) of five reviewed for hospitalization. The facility census was 97. Findings include: 1. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, peripheral vascular disease, diabetes mellitus, chronic kidney disease, psychosis, osteoporosis, major depressive disorder, hypertension, and dysphagia. The resident had a legal guardian. Review of the quarterly minimum data set (MDS) assessment dated [DATE] was reviewed revealed the resident had severely impaired memory and recall, and required the physical assistance of at least one staff person for all activities of daily living (ADLs), with the exception of eating for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, shower schedule review, and staff and resident interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary care and services to maintain good grooming and hygiene. This affected five residents (#63, #72, #73, #83, and #95) of five reviewed for ADLs. The facility census was 97. Findings include: 1. Review of the medial record revealed Resident #73 was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, peripheral vascular disease, diabetes mellitus, chronic kidney disease, psychosis, osteoporosis, major depressive disorder, hypertension, and dysphagia. Review of the minimum data set (MDS) dated [DATE] revealed the resident had severely impaired memory and recall, and required the physical assistance of one to two staff persons for all ADLs, with the exception of eating for which she required only supervision. The assessment specified the 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 medical record review, observation, and staff interview the facility failed to provide an ongoing activity program to meet each resident's individual needs and preference. This affected six residents ( #12, #20, #56, #63, #69, and #73) of nine residents reviewed for activities. The facility census was 97. Findings include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, osteoporosis, major depressive disorder, schizophrenia, shared psychotic disorder, acute respiratory failure with hypoxia, alcohol dependence with alcohol-induced persisting dementia, dementia without behavioral disturbance, and phobic anxiety disorders. The resident resided on the secure unit for female residents with dementia, Unit 200. Review of Resident #12's current physician's orders revealed an order for the resident to reside on the secured unit, and to have hospice services effective 02/20/19 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of water temperature monitoring log, review of plumber service report and review of facility policy and procedures, the facility failed to maintain water temperatures in resident areas at a safe and comfortable level. This had the potential to affect 11 independently mobile residents on Unit 200 (#26, #36, #42, #45, #54, #53, #55, #56, #64, #70 and #80), the secured unit for female residents with dementia, as well as six independently mobile residents located (#24, #25, #68, #90, #93, and #100) in the unsecured section of the 200 Unit (rooms number 200 included in the 300 B Unit). The facility census was 97. Findings include: On 02/25/20 at 11:36 A.M. the hot water at the hand sink in Resident #73's bathroom was taken and noted to be 130 degrees Fahrenheit (F). On 02/25/20 at 11:38 A.M. the hot water at the hand sink in Resident #69's bathroom was taken and noted to be 135 F. On 02/25/20 at 11:45 A.M. Maintenance Director (MD) #26 was asked to report to the secured…

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 3. On 02/24/20 at approximately 12:15 P.M., Resident #37 was observed walking up and down the locked 300 hall men's dementia unit. He was observed spitting out thick secretions from his mouth on his hands, lower arms, and on to the floor. Some of the secretions looked like undigested pureed food. His hands were observed by two surveyors to be glistening with sputum. The male housekeeper was off the unit at the time as he was on his lunch break. The sputum was on the floor for approximately 15 minutes until Licensed Practical Nurse (LPN) #48 brought some towels and washcloths from the other adjacent unit. When asked what she was doing with the linens, she stated it was to clean up the sputum. She was not using any disinfectant to clean up the sputum/secretions. On 02/27/20 at 2:40 PM on 02/27/20, Housekeeping Director #10 was interviewed and stated unless the nurse informed the housekeeper about the sputum they cleaned up, he would not mop and disinfect the area. He was at lunch/break and did not know this had…

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 review of maintenance request logs, the facility failed to provide a functional, sanitary, and comfortable environment for residents, staff, and the public. This had the potential to affect all 24 Residents (#9, #12, #14, #22, #26, #30, #34, #36, #42, #45, #49, #52, #53, #54, #55, #56, #63, #64, #67, #69, #70, #73, #88, and #91) who resided on Unit 200, as well as one Resident (#13) on Unit 100. The facility census was 97. Findings include: 1. On 02/27/20 at 10:35 A.M. a tour of the secured unit for female residents with dementia, Unit 200, was conducted with Maintenance Director (MD) #26. While touring the unit the following was observed: a) In the large unit dining/activity room there were two long dining tables of which the laminate on the top was heavily worn through. There were multiple scrapes and scuffs on the walls, and one area to the left of the mounted television where a large area of paint and the outer surface of the dry wall was missing. b) In the small…

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 interview, the facility failed to ensure residents were enabled and encouraged to make choices on what they preferred to eat at mealtimes. This affected one (Resident #5) of five reviewed for nutrition. The facility census was 97 residents. Findings include: Review of Resident #5's medical record, revealed he was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol induced dementia, dysphagia, severe protein calorie malnutrition, abnormal weight loss, schizoaffective disorder, extrapyramidal and movement disorder, gastro-esophageal reflux disease, constipation, arthritis, Vitamin D deficiency, nuclear cataract, cerebral atheroslerosis, general anxiety disorder, hypertension, major depressive disorder, delusions, cerebral ataxia, neuropathy, hearing loss, and ventral hernia. The resident was on a pureed diet with pudding thick liquids. He received a frozen supplement at each meal (magic cup) and 90 cubic centimeters (cc) 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 provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) letter 48 hours prior to being discharged from Medicare Part A Services. This affected one (Resident #202) of three sampled residents. The facility census was 97 residents. Findings include: Review of Resident #202's medical record revealed he was admitted to the facility on [DATE], with diagnoses including anemia, hypertension, renal failure, and hyperkalemia. Further review of SNF Beneficiary Protection Notification Review, revealed the resident began Medicare Part A services on 10/02/19, and the resident's last covered day (LCD) for therapy services was on 10/11/19. The resident was provided notice his Part A benefits were ended on 10/11/19, the same day, which gave him no time for an appeal. On 02/27/20 at 10:00 A.M., Social Services Director #131, confirmed the resident was not given the required 48 hours notice prior to being cut from skilled therapy services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff and resident interview, the facility failed to implement each residents plan of care related to activity needs and preference. This affected three residents (#12, #69 and #73) of nine residents reviewed for activities. The facility census was 97. Findings include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, osteoporosis, major depressive disorder, schizophrenia, shared psychotic disorder, acute respiratory failure with hypoxia, alcohol dependence with alcohol-induced persisting dementia, dementia without behavioral disturbance, and phobic anxiety disorders. The resident resided on the secure unit for female residents with dementia, (Unit 200). Review of Resident #12's current physician's orders revealed an order for the resident to reside on the secured unit, and to have hospice services effective 02/20/19 for Parkinson'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 and interviews the facility failed to develop and implement a discharge plan for residents. This affected two (#95, #103) of three residents review for discharge planning. The facility census was 97. Findings include: 1. Review of Resident #95's medical record revealed an admission date of 04/12/18 with diagnoses of Huntington' disease, osteoarthritis, peripheral vascular disease, paranoid schizophrenia, and mood disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive assist of two for bed mobility, transfer and toileting, extensive assist of one for dressing, ambulation, personal hygiene, and eating. The MDS indicated no evidence of depression, but presence of delusions and rejections of care four to six days a week. Review of a care plan dated 09/16/18 indicated resident would stay at the facility long term. Review of progress notes dated 01/07/20 indicated a referral was sent to another…

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 attempt gradual dose reductions (GDR) for residents receiving psychotropic medications. This affected two (#39 and #95) of six residents reviewed for unnecessary medications. The facility also failed to ensure a resident was receiving the correct dose of a psychotropic medication. This affected one (Resident #69) of six residents reviewed for unnecessary medications. The facility identified 78 residents as receiving psychotropic medications. The census was 97 Findings include: 1. Review of the medical record revealed Resident #39 was admitted on [DATE] with diagnosis of diabetes, hypertension, hypothyroidism, anxiety, bipolar disorder, psychosis, and gastroesophageal reflux disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had intact cognition and required supervision for completion of activities of daily living. The MDS indicated no evidence of depression, but presence of…

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

Based on observation, staff interview and review of facility policy the facility failed to discard expired medications and Control Solution (glucometer testing solution). This directly affected one (Resident #94) and had the potential to affect all residents of the facility. The census was 97. Findings include: Observation of the 300-hall medication cart on 02/26/20 at 11:40 A.M. revealed a brown bag labeled for Resident #94 containing 15 one milliliter (ml) vials of naloxone (emergency medication to counter opioid overdose) liquid medication. Eight of the one ml vials had an expiration date of 01/10/19. During the observation a one ml vial of Control Solution with an expiration date of 01/2020. At the time of the observation Licensed Practical Nurse (LPN) #75 was interviewed and verified the naloxone and Control Solution were expired. She reported the Control Solution was used every nightshift to calibrate the glucometers used to assess resident blood sugars. She denied any other Control Solution was in the medication cart. Interview on 02/26/20 at 11:45 A.M. with Assistant…

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 review of facility policy the facility failed to ensure documentation of wound treatments was completed in a residents records. This affected one (Resident #12) of one reviewed for pressure ulcer treatments. The facility identified four residents with pressure ulcers. The resident census was 97. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of schizophrenia, hypertension and dementia without behavioral disturbance. The resident had pressure ulcers on her right thigh, right ischium and sacrum. Review of physician orders revealed the right ischium was to be cleansed, Santyl (debrieder) applied and cover the wound with a four by four gauze and an abdominal (ABD) pad every shift for wound care. The right hip ulcer was to be cleansed, patted dry, Santyl applied and covered with a four by four gauze and an ABD pad every shift for wound care. Review of the Treatment Administration Record…

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