The Laurels Of Walden Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to obtain an audiology consult for a resident in a timely manner. This affected one (Resident #46) of four residents reviewed for ancillary services. The facility census was 209.Findings include: Review of the medical record for Resident #46 revealed an admission date of 11/12/18. Diagnoses included Parkinson's disease, dementia, and hearing loss. Review of Resident #46's care plan dated 06/05/19 revealed he had impaired communication related to mixed conductive and sensorineural bilateral hearing loss and that he wore hearing aids. Interventions listed was to check bilateral hearing aide placement and functioning and to refer to audiology for hearing consult. Review of Resident #46's audiology visit on 10/26/22 revealed he was recommended to wear daily hearing aids. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had moderate…

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 reviews, observations, staff interviews and review of facility policy, the facility failed to provide residents who had contractures their splint devices as physician ordered. This affected two (Residents #144 and 209) of four residents reviewed for range of motion. The facility identified 19 residents with contractures. The facility census was 209. Findings include: 1. Review of the medical record for Resident #144 revealed an admission date of 03/27/17 . Diagnoses included paralytic syndrome, polyneuropathy, and contracture right hand and wrist 10/01/18. Review of the physician orders dated 11/12/22 revealed Resident #144 was to have a right palm protector applied between 7:00 A.M. and 7:00 P.M. for up to eight hours daily. Review of Resident #144’s care plan dated 10/20/23 and last updated 08/07/25 revealed Resident #144 had a functional ability deficit and required assistance with self-care related to his contracture of his right hand and wrist. A goal was to improve of maintain current level…

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, staff interviews, and facility policy review, the facility failed to complete a thorough fall investigations, failed to ensure residents had adequate footwear to prevent accidents, and failed to appropriately secure the resident's smoking materials. This affected three (Residents #70, #84, and #110) of 12 residents reviewed for accidents. The facility census was 209. Findings include: 1. Review of the medical record for Resident #84 revealed a re-admission date of 12/20/24. Diagnoses included Alzheimer’s disease with late onset, dementia, and osteopenia. Review of the fall risk assessment dated [DATE] revealed Resident #84 was at risk for falls. Review of the plan of care dated 05/17/24 revealed Resident #84 was at risk for falls due to impaired cognition and mobility limitations. Interventions included providing adequate lighting, keeping call light and commonly used items within reach, placing the call light within reach and encouraging the resident to use it 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 record review, observations, staff interviews, policy review, and review of hospital records, the facility failed to provide adequate respiratory care for Resident #47 who had localized fly larvae infestation to her tracheostomy and stoma and required hospitalization. This affected one (#47) of five residents reviewed for respiratory care. The facility identified 36 residents residing on the tracheostomy unit. The facility census was 209. Findings included: Review of Resident #47's medical record revealed an admission date of 10/23/24. Diagnoses included acute and chronic respiratory failure, hemiplegia and hemiparesis, tracheostomy and ventilator dependent. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Resident #47 was also totally dependent on staff for all care including tracheostomy care. Review of the active physician orders revealed Resident #47 was to receive tracheostomy care every 12 hours which included changing of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to consistently evaluate the effectiveness of regularly scheduled opioid pain medication in accordance with the resident's comprehensive care plan. This affected one (#159) of five residents reviewed for unnecessary medications. The facility census was 209. Findings include:Review of Resident #159's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included fibromyalgia (long-term condition that involves widespread body pain) and polyarthritis (a form of arthritis affecting five or more joints simultaneously, causing pain, swelling, warmth, and stiffness). Review of the physician order summary dated 03/04/25 revealed Resident #159 had an order for Tramadol (an opioid and treats moderate to severe pain) 50 milligrams (mg) give one tablet by mouth two times a day for polyarthritis. Review of the care plan dated 06/29/25 revealed Resident #159 was at risk for chronic pain and the interventions…

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, resident and staff interviews, and review of facility policy, the facility failed to identify post traumatic stress disorder (PTSD) triggers on the care plan for Resident #48 and failed to assess Resident #8 for PTSD upon admission. This affected two (Residents #8 and #48) of five residents reviewed for mood and behavior. The facility census was 209.Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 06/17/25. Diagnoses included PTSD, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was cognitively intact and did not have behaviors. Review of the social services evaluation dated 06/27/25 revealed Resident #48 had experienced a loss of a significant other and a traumatic event of a motor vehicle accident with mass casualties. Symptoms due to her PTSD included flashbacks, hypervigilance, fear, severe anxiety, loneliness and unwanted thoughts. Triggers included people,…

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 Food and Drug Administration (FDA) guidance, and staff interviews, the facility failed to ensure medications were properly stored. This affected two of six medication carts observed. The facility identified 11 medication cart in the facility. This affected three residents (#33, #53, and #237). The facility census was 209.Findings include:1. Observation of the 500-hall medication cart on 08/07/25 at 9:30 A.M. revealed an unopened bottle of Chlorhexidine (a topical antiseptic) labeled for Resident #33 with the expiration date of February 2025.Interview with Unit Manager #110 on 08/07/25 at 9:32 A.M. verified the Chlorhexidine was expired.2. Observation of 400-hall medication cart on 08/07/25 at 10:00 A.M. revealed a vial of Novolin 70/30 (insulin) with an open date of 06/27/25 for Resident #237. There was also a Lantus (insulin) pen without an open date for Resident #53.Interview with Licensed Practical Nurse (LPN) #530 on 08/07/25 at 10:02 A.M. verified the vial of Novolin 70/30 should have been discarded after 30 days. LPN #530 added Resident #237 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.

Based on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance and review of facility policy, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) in designated resident rooms. This affected one (Resident #10) of four residents reviewed for EBP. The facility census was 209. Findings included:Review of the medical record for Resident #10 revealed an admission date of 07/15/21. Diagnoses included chronic obstructive pulmonary disease. Review of Resident #10's physician orders for 08/01/25 to 08/11/25 revealed an active order for Resident #10 to be on EBP related to chronic wound. Observation on 08/05/25 at 2:40 P.M. revealed Certified Nursing Assistant (CNA) #115 assisting Resident #10 at the bedside with gloves on. He went into the resident's bathroom and exited out of the room with gloved hands. CNA #115 was not wearing a gown during provision of care. Interview on 08/05/25 at 2:42 P.M. with CNA #115 confirmed he performed incontinence care for Resident #10 with gloves only. CNA #115 confirmed he…

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, medical record review, staff interview, and review of the facility policy, the facility failed to ensure the call light was positioned within reach of a resident. This affected one (#15) of 51 residents observed for call light placement. The facility census was 209. Findings include:Medical record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of neck of left femur, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognitive function and required substantial, maximal assistance with mobility. Review of Resident #15's plan of care, dated 06/02/25, revealed Resident #15 had an Activities of Daily Living (ADL) functional deficit, and required substantial to maximal assistance with all self-care. Interventions for Resident #15 included encourage the resident to use bell/call light to call for assistance. Observations…

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, medical record review, and staff interviews, the facility failed to monitor bruising and bleeding risk for a resident on an anticoagulant. This affected one resident (Resident #45) out of three residents reviewed for anticoagulant medications, and had the potential to affect 48 residents that the facility identified as being on anticoagulant medication. The facility census was 205 residents. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, mood disorder, anemia, anxiety disorder and heart failure. Review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE] revealed that her Brief Interview for Mental Status (BIMS) was 15, indicative of intact cognition. Review of her MDS also revealed that she was receiving anticoagulant medication. Review of Resident #45's physician orders revealed that effective 01/18/25, she had physician orders 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, staff interview, and review of facility policy, the facility failed to investigate or assess a resident after a significant weight gain. This affected one resident (Resident #208) out of four residents reviewed for weight changes. The facility census was 205 residents. Findings include: Review of the medical record revealed Resident #208 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, encounter for tracheostomy, intracerebral hemorrhage, end stage renal disease, dependence on renal dialysis, dysphagia, and hemiparesis. Review of Resident #208's nutrition care plan dated 11/05/24 revealed he was at risk for nutritional decline. An intervention was to observe and evaluate weight and weight changes. Review of Resident #208's Minimum Data Set (MDS) assessment on 02/20/25 revealed that he was cognitively impaired. Review of Resident #208's weight record revealed that he weighed 169.1 pounds (lbs) on 03/06/25 and he weighed…

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, medical record review, resident interview, staff interviews, review of admission checklists and review of facility policy, the facility failed to reconcile admission orders with a resident's previous medication orders to provide required eye drops per resident's expectations and physician orders. This affected one resident (Resident #156) out of three residents reviewed for medication administration. The facility census was 205 residents. Findings Include: Review of the medical record revealed Resident #156 was admitted on [DATE] readmitted on [DATE] with diagnoses that included end stage renal disease, status post cadaver - donor kidney transplant, dependence on renal dialysis, congestive heart failure, presence of cardiac pacemaker, immunodeficiency due to drugs, type two diabetes mellitus with diabetic neuropathy, depression, chronic pain, and sarcoidosis. Review of the physician orders dated 03/23/25, prior to the hospitalization, revealed Resident #156 was to receive Brimonidine…

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 monitor side effects of a resident on antipsychotic medications. This affected one resident (Resident #106) out of three residents reviewed for antipsychotic medications, and had the potential to affect 47 residents that the facility identified as being on antipsychotic medication. The facility census was 205 residents. Findings include: Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, schizophrenia, hypothyroidism, dementia, and drug induced dyskinesia. Review of Resident #106's care plan dated 05/08/19 revealed that she was at risk for adverse reaction and side effects related to receiving psychotropic medication due to the resident taking an antipsychotic for schizophrenia. Interventions included observing for side effects related to taking antipsychotic medications such as sedation, headaches, dizziness,…

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, resident and staff interview, review of a facility self reported incident, review of facility investigation, review of hospital records, and facility policy review, the facility failed to ensure one resident (Resident #145) was free from physical abuse in the facility. The deficient practice affected one (Resident #145) of three reviewed for abuse. The facility census was 204. Findings Include: Review of the medical record for Resident #145 revealed an admission date of 02/01/21. Diagnoses included fracture of nasal bones (01/14/25), hemiplegia affecting unspecified side, personal history of traumatic brain injury, difficulty in walking, other seizures, and unspecified mental disorder due to a known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, revealed Resident #145 had intact cognition. The resident required minimal assistance which varied from independent to supervision from staff to complete Activities of Daily Living (ADLs). The resident exhibited physical and other behaviors toward others one…

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, resident and staff interviews, review of a facility self reported incident, review of the facility investigation, and facility policy review, the facility failed to complete a thorough investigation of an allegation of physical abuse of one resident (Resident #145). The deficient practice affected one resident (Resident #145) of three reviewed for abuse. The facility census was 204. Findings Include: Review of the medical record for Resident #145 revealed an admission date of 02/01/21. Diagnoses included fracture of nasal bones (01/14/25), hemiplegia affecting unspecified side, personal history of traumatic brain injury, difficulty in walking, other seizures, and unspecified mental disorder due to a known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, revealed Resident #145 had intact cognition. The resident required minimal assistance which varied from independent to supervision from staff to complete Activities of Daily Living (ADLs). The resident exhibited physical and other behaviors toward…

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, staff interview, and policy review, the facility failed to ensure timely notification to the physician or Certified Nurse Practitioner (CNP) of abnormal laboratory values for Resident #37. This affected one (Resident #37) of three residents reviewed for quality of care. The facility census was 215. Findings include: Review of the closed medical record for Resident #215 revealed an admission date of 10/22/24. Medical diagnoses included chronic systolic and diastolic heart failure, chronic obstructive pulmonary disease, type two diabetes, chronic respiratory failure, chronic kidney disease, paroxysmal atrial fibrillation, and encounter for adjustment and management of automatic implantable cardiac defibrillator. Review of Resident #215's hospital discharge notes dated 10/22/24 revealed the resident had a scheduled visit with the cardiologist on 11/06/24. The hospital indicated he had recommended outpatient testing which included obtaining a Basic Metabolic Panel (BMP) and magnesium level in three to five days. Review of Resident #215's physician orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to appropriately investigate a resident incident. This affected one (Resident #301) of three resident incidents reviewed. The census was 219. Findings Include: Resident #301 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disease, chronic kidney disease, asthma, acute respiratory failure, hypotension, atrial fibrillation, anemia, vascular dementia, congestive heart failure, epilepsy, dorsalgia, alcohol abuse, diverticulitis, suicidal ideation, hydronephrosis, restlessness and agitation, nicotine dependence, sleep apnea, polyneuropathy, and depression. Review of his minimum data set (MDS) assessment, dated 08/28/24, revealed he had a severe cognitive impairment. Review of Resident #301 progress notes and fall investigation, dated 10/05/24, revealed he had an unwitnessed fall while in the facility. Because he had an unwitnessed fall, the facility started neurological checks. Review of the neurological…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (#11) attended a scheduled medical appointment out of the facility out of three residents reviewed. The facility census was 210. Findings include: Review of the medical record for Resident #11 revealed an admission date of 03/12/22. Diagnoses included but were not limited to demyelinating disease of central nervous system, chronic respiratory failure with hypoxia, tracheostomy status, and quadriplegia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. The resident was assessed to require total dependence on all aspects of care. Review of Resident #11's After Visit Summary from Ohio Health dated 08/06/24 at 9:30 A.M. revealed an appointment for 08/21/24 at 10:00 A.M. with Ohio Health Neuroscience. Further review of Resident #11's medical record revealed no record of the 08/21/24 10:00 A.M. appointment…

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 the facility policy the facility failed to provide care and supervision to prevent residents from eloping from the facility. This affected one (Resident #10) of ten facility-identified residents at risk for elopement. The facility census was 202. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 12/20/23 with diagnoses including metabolic encephalopathy, type two diabetes, hypertension, and chronic kidney disease. Resident #10 was discharged to the hospital on [DATE] following an elopement from the facility. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 12/20/23 revealed resident was cognitively impaired. Review of the preadmission hospital records for Resident #10 dated 11/27/23 revealed resident was diagnosed with acute encephalopathy, possible multi-infarct dementia and metabolic encephalopathy from hypoglycemia. Further review of the hospital records revealed Resident #10'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, resident interview, and staff interview, the facility failed to ensure a resident room was maintained in a homelike manner. This affected two (Resident #3 and Resident #4) of five resident rooms reviewed for a homelike environment. The facility census was 206. Findings include: Observation on 11/15/23 at 1:30 P.M. of Resident #3 and Resident #4's room revealed the wood paneling floor next to Resident #4's bed was chipped and the surface underneath the wood paneling floor was exposed. Observation on 11/15/23 at 1:30 P.M. of Resident #3 and Resident #4's bathroom revealed the floor in the bathroom had an approximately two-foot crack in it. Additionally, the flooring had bubbled up around the edges of the bathroom and had turned gray in spots which was not the natural color of the floor. Interview on 11/15/23 at 1:30 P.M. with Resident #3 revealed the bathroom floor appeared as though it needed to be replaced. Interview on 11/15/23 at 1:41 P.M. with Director of Maintenance #321 verified the wood paneling floor next to Resident #4's bed was chipped and the surface…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, self reported incident (SRI) review, and policy review, the facility failed to properly store controlled substances. This affected one resident (Resident #20) out of the one resident reviewed for controlled substance storage. The facility census was 201. Findings include: Review of the medical record for Resident #20, revealed an admission date of 03/07/22. Diagnoses included: metabolic encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, centrilobular emphysema and restlessness and agitation. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 10 out of 15. The resident was assessed to require extensive assistance with two person physical assist with bed mobility, transfers, and extensive assistance with one-person physical assistance with toilet use and dressing. Review of physician orders revealed Resident #20 was ordered lorazapam (Ativan) one…

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 Section C for assessing a resident's cognition and mood were assessed in the Minimum Data Set (MDS) 3.0 assessment. This affected six (Residents #77, #151, #57, #406, #15, and #25) of six residents reviewed for accuracy of assessments. The facility census was 207. Findings include: 1. Review of the medical record for Resident #77 revealed an admission date of 01/31/22 with diagnoses including major depressive disorder, paraplegia, neurogenic bowel, neuromuscular dysfunction of the bladder, panic disorder, major depression, and polyneuropathy. Review of Resident #77's quarterly MDS 3.0 assessment dated [DATE] revealed all areas in Section C (Cognition) and Section D (Mood) were marked as 'not assessed.' 2. Review of the medical record for Resident #151 revealed an admission date of 06/10/22 with diagnoses including end stage renal disease with dependence on dialysis, unspecified protein calorie malnutrition,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to ensure Resident #12's dignity was maintained by ensuring she had clothes available to her. This affected one (Resident #12) of one resident reviewed for dignity. The facility census was 207. Findings include: Review of the medical record revealed Resident #12 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, cognitive communication deficit, dysphagia, acute respiratory failure with hypoxia, end stage renal disease with dependence on renal dialysis, multiple sclerosis, peripheral vascular disease, and rheumatoid arthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had intact cognition and required the extensive assistance of two persons for dressing. Observation on 04/24/23 at 12:30 P.M. and 3:30 P.M. revealed Resident #12 in her bedroom, she was in a hospital gown. Observation on 04/25/23 at 8:30 A.M. revealed Resident #12 in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and manual review the facility failed to complete a discharge Minimum Data Set (MDS) resident assessment. This affected one (Resident #100) out of three residents reviewed for resident assessments. Facility census was 207. Findings include: Record review revealed Resident #100 was admitted to the facility on [DATE] for short term therapy and skilled nursing services. Resident #100 was discharged from the facility on 12/01/22. Review of Minimum Data Set (MDS) assessments for Resident #100 revealed an entry MDS was completed on 11/18/22 and an admission MDS was completed on 11/25/22. There was no discharge MDS completed. Interview on 04/26/23 at 11:36 A.M. with Licensed Practical Nurse (LPN) #419 confirmed Resident #100 did not have a discharge MDS completed. Review of Resident Assessment Instrument (RAI) manual revised October 2019 Chapter two, Assessments for the Resident Assessment Instrument (RAI), revealed, Discharge Assessment refers to an assessment required on resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to complete quarterly care conferences. This affected one (Resident #44) of three residents reviewed for care conferences. Additionally, the facility failed to ensure a resident's care plan was updated to reflect current advanced directives. This affected one (Resident #81) of one reviewed for care planning advanced directives. The facility's census was 207. Findings include: 1. Review of Resident #44's medical record revealed the resident was admitted to the facility [DATE] with the diagnoses of Parkinson's, unspecified atrial fibrillation, dementia, hypertension, fibromyalgia, and osteoporosis. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively intact and had no behaviors. Resident #44 required extensive assistance with dressing and personal hygiene and supervision for all other activities of daily living. Further review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #159's preferred activities were available to him. This affected one (Resident #159) of two residents reviewed for activities. The facility's census was 207. Findings include: Review of the medical record revealed Resident #159 admitted to the facility on [DATE] with diagnoses including anoxic brain damage, dysphagia, cognitive communication deficit, pressure ulcer of sacral region stage four, systolic heart failure, alcohol abuse, colostomy, and retention of urine. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #159 had severely impaired cognition. The resident was dependent on staff for bed mobility and transfers Review of the plan of care dated 06/03/22 revealed Resident #159 had a potential for impaired social interaction or social isolation related to impaired cognition and physical limitations. He enjoyed watching activities, movies inside his own room, and happy hour…

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 and procedure, the facility failed to ensure residents secured their smoking contraband. This affected one (Resident #25) out of five residents reviewed for accidents. The facility census was 207. Findings include: Review of the medical record for Resident #25 revealed an admission date of 11/15/22 and the diagnoses of schizophrenia, disorganized schizophrenia, and nicotine dependence. Review of the care plan dated 11/16/22 revealed Resident #25 wished to use smoking products and has been assessed as being safe to smoke with supervision and the resident had episodes of choosing not to follow the facility smoking policy and being resistive to turning over smoking materials. Interventions included to assess her ability to smoke safely per facility policy, educate the resident on the smoking policy, the resident is independent with managing smoking materials and accessing the lock box, and staff will maintain all smoking paraphernalia…

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, staff interviews, review of the facility policy, and medical record review, the facility failed to ensure Resident #406's nephrostomy bag was in the proper position at all times to prevent backflow of urine into the bladder. This affected one (Resident #406) of two residents reviewed for catheters. The facility census was 207. Findings include: Review of Resident #406's medical record revealed Resident #406 was admitted on [DATE]. Diagnoses included end stage renal disease with dependence on dialysis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and obstructive and reflux uropathy. Review of the physician order dated 04/11/23 revealed Resident #406 had a nephrostomy tube to her right flank. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #406 had mildly impaired cognition and had an indwelling catheter. Review of the plan of care dated 04/17/23 revealed Resident #406 was at risk for urinary tract…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the Federal Drug Administration Approving Labeling Text, the facility failed to ensure a resident did not receive an antipsychotic medication without an appropriate diagnosis. This affected one (Resident #83) of five residents reviewed unnecessary medication. The facility census was 207. Findings include: Record review for Resident #83 revealed Resident #83 was admitted to the facility on [DATE]. Diagnoses included anxiety, major depression disorder, and chronic pain. The resident's diagnosis list did not include bipolar disorder. Review of Resident #83's physician orders revealed an order dated 04/03/23 for Depakote 125 milligrams (mg) administered three times per day for agitation. Review of the psychiatric progress note dated 01/17/23 revealed Resident #83 was on Depakote 125 milligrams (mg) for bipolar disorder. Interview with Registered Nurse (RN) #400 confirmed the physician order for Resident #83 of Depakote 125 milligrams (mg) for agitation. Review…

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

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a medication error rate below five percent (%). There were five medication errors out of 28 opportunities resulting in a 17.86% medication error rate. This affected two (Resident #34 and #131) of four residents observed during medication pass. The facility census was 207. Findings include: 1. Review of the medical record for Resident #131 revealed an admission date of 07/09/19. Diagnoses included gait abnormalities, muscle weakness, and need for assistance with personal care. Review of the physician orders revealed on 12/14/20, Resident #131 was ordered Senna Plus Docusate Sodium 8.6-50 milligrams (mg) with instructions to give one tablet daily for constipation. Review of the care plan dated 07/18/19 revealed Resident #131 was at risk for constipation related to decreased mobility with interventions to administer medications as ordered and observe for ineffectiveness/side effects. Observation and interview on 04/25/23 at 9:51 A.M. with Licensed Practical Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure Resident #159's activity participation was recorded accurately and by the staff who initiated it. This affected one (Residents #159) of 39 resident records reviewed. The facility census was 207. Findings include: Review of the medical record revealed Resident #159 admitted on [DATE] with diagnoses including anoxic brain damage, systolic heart failure and retention of urine. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #159 had severely impaired cognition. Review of the April 2023 activity documentation report downloaded on 04/25/23 at 3:50 P.M. revealed Resident #159 was listed as conversing with others on 04/04/23, 04/18/23, 04/24/23, and 04/25/23. Resident #159 was listed as watching television or movies on 04/04/23, 04/18/23, 04/24/23, and 04/25/23. No other activities were documented. On 04/27/23 at 4:27 P.M. Activities Director #571 provided an April 2023 activity documentation report…

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 medical record review, the facility failed to ensure personal protective equipment (PPE) was disposed of properly after providing care for Resident #179, who had Methicillin-Resistant Staphylococcus Aureus (MRSA) in her wound. This affected one (Resident #179) of one resident under transmission-based precautions. The facility census was 207. Findings include: Review of the medical record for Resident #179 revealed an admission date of 09/13/22 with diagnoses including cellulitis of left lower limb, peripheral vascular disease, and open wound to the left lower leg. Review of the physician order dated 04/06/23 revealed Resident #179 had an order for contact isolation for MRSA in the wound. Interview on 04/24/23 at 10:25 A.M. with Licensed Practical Nurse (LPN) #451 revealed Resident #179 was under contact isolation for a wound to her feet and those providing care to the resident required personal protective equipment (PPE) including a gown. Observation on 04/24/23 at 10:30 A.M. revealed Resident #179 had no biohazard containers in her room.…

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, facility policy and procedure review and interview the facility failed to ensure the proper personal protective equipment (PPE) was worn when providing care for residents who tested positive for COVID-19 to prevent the potential spread of COVID-19. This had the potential to affect 33 residents (#37, #93, #125, #10, #178, #156, #153, #98, #56, #136, #161, #127, #3, #59, #101, #84, #14, #11, #114, #139, #15, #38, #103, #55, #130, #137, #108, #163, #33, #42, #120, #106 and #121) who resided on the 300 unit (non-COVID unit) who received care from Registered Nurse (RN) #213. The facility census was 185. Finding include: The facility identified seven residents, Resident #7, #159, #83, #138, #4, #71, and #85 who resided on the facility dedicated COVID-19 unit and who were in isolation for COVID-19 at the time of the survey. On 11/02/22 at 12:02 P.M. observation of the 300 unit revealed a portion of the unit had been converted into a dedicated COVID-19 unit. A section of the unit contained a set of double doors which were closed with signs posed. The signage included…

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 Resident #146 was provided the opportunity to participate in decisions regarding the continued use of an indwelling urinary catheter. This affected one resident (#146) of the three residents who were reviewed for urinary catheters or urinary tract infections. Findings include: Record review revealed Resident #146 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, end stage renal disease, benign prostatic hyperplasia with lower urinary tract symptoms, dependence on renal dialysis and legal blindness. Review of the facility Nursing Comprehensive Evaluation, dated 09/20/22 revealed the resident was assessed to have an indwelling urinary (Foley) catheter. Review of the a certified nurse practitioner (CNP) progress note, dated 09/22/22 revealed the resident had little urine and self catheterized. Nursing to provide catheterization supplies and resident to self catheterize every eight hours as…

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, facility policy and procedure review and interview the facility failed to ensure Resident #164 was not physically restrained for staff convenience. This affected one resident (#164) of the two residents reviewed for physical restraints. Findings include: Record review revealed Resident #164 was admitted to the facility on [DATE] with diagnoses including Huntington's disease, major depressive disorder, unspecified fall, muscle wasting, mild cognitive impairment and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/05/22 revealed the resident exhibited moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 10 (out of 15). This resident was assessed to require extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for toileting and walking. This assessment did not note the use of any type of restraints. On 10/31/22 at 10:15…

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

Based on record review, and staff interview the facility failed to ensure Resident #116 was referred for a Pre-admission Screening and Resident Review (PASARR) assessment following a significant change in status and new mental health diagnoses. This affected one resident (#116) of five residents reviewed for PASARR. Findings include: Review of the medical record for Resident #116 revealed an initial admission date 12/08/20 and a re-entry date of 01/21/22. Resident #116 had current diagnoses including major depressive disorder, anxiety, suicidal ideation's, schizoaffective disorder, and psychosis. Review of Resident #116's PASARR, dated 12/03/20 revealed under Section D: Indications of Serious Mental Illness, Mood Disorder was the only diagnosis noted in this section. The PASARR Determination letter revealed, Not Applicable. Review of Resident #116's care plan, dated 12/08/20 and revised 08/03/22 revealed Resident #116 had potential for fluctuations in mood related to diagnoses of major depressive anxiety, insomnia, schizophrenia, psychosis, impulsive at times. Interventions include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to timely complete a Preadmission Screen and Resident Review (PASARR) for Resident #147 at the time of admission. This affected one resident (#147) of five residents reviewed for PASARR. Findings include: Record review revealed Resident #147 was admitted to the facility on [DATE] and had diagnoses including hallucinations, schizophrenia, major depressive disorder, generalized anxiety disorder, suicide attempt, and personal history of traumatic brain injury. Review of the Preadmission Screening and Resident Review (PASARR) Identification Screen revealed the screen had not been completed until 05/13/22, almost six months after the resident was admitted to the facility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/08/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15. The assessment revealed the resident required limited assistance from one staff…

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, facility policy review and interview the facility failed to ensure timely follow up appointments were scheduled to promote an optimal continuum of care for Resident #23 and Resident #174. The facility also failed to ensure preventative skin interventions were provided as ordered for Resident #33. This affected three residents (#23, #33 and #174) of 37 sampled residents reviewed for quality of care. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including muscle weakness, repeated falls, schizoaffective disorder, muscle wasting and atrophy, altered mental status, bipolar disorder and chronic pain syndrome. Review of the nursing progress note, dated 09/29/22 revealed staff alerted the nurse Resident #23 was on the floor. The resident was observed to be laying on his right side with a cane near the resident. The resident stated he became lightheaded sometimes and while ambulating in the hall lowered himself to the…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure interventions related to contracture management were in place for Resident #39, Resident #77 and Resident #158 as ordered. This affected three residents (#39, #77 and #158) of four residents reviewed for limited range of motion. Findings include: 1. Review of the medical record for Resident #39 revealed an initial admission date of 08/15/22 with the latest readmission date of 09/30/22 and diagnoses including acute and chronic respiratory failure, pneumonia, aphonia, dysphagia, muscle wasting and atrophy, sepsis, heart failure, cerebral palsy, severe protein-calorie malnutrition, metabolic encephalopathy, gastro-esophageal reflux disease, gastrostomy, tracheostomy, hyperlipidemia, neuromuscular dysfunction of bladder, anemia and dependence on ventilator. Review of the nursing comprehensive evaluation dated 08/15/22 revealed the resident was admitted to the facility with contractures and had a diagnoses of quadriplegia. Review of the monthly physician's orders for…

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

Based on observation, record review, review of dialysis communication forms, facility policy and procedure review and interview the facility failed to ensure accurate dialysis communication was communicated between the facility and dialysis center for Resident #126. This affected one resident (#126) of two residents reviewed for hemodialysis. Findings include: Review of the medical record for Resident #126 revealed an admission date on 10/20/21 with medical diagnoses including end stage renal disease, dependence on renal dialysis, chronic viral hepatitis C, and acquired absences of left leg above the knee and right toe(s). Review of the care plan, dated 10/20/21 (and revised 11/04/22) revealed Resident #126 was at risk for complications related to dialysis. Interventions included the facility would utilize the Dialysis Communication form to communicate with the dialysis center. Send the dialysis communication book to the dialysis center with each appointment. Upon return from the dialysis center review the communication book including any progress notes. Provide an update to the…

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