Carecore At Mary Scott

Based on facility policy review, record review, and interview, the facility failed to ensure a resident's discharge was accurately and thoroughly documented in the medical record. This affected one (#78) of two residents reviewed for discharge requirements. The facility census was 71.Findings include: An admission Record revealed the facility had admitted Resident #78 on 07/20/23. According to the admission Record, the resident had a medical history that included diagnoses of severe recurrent major depression without psychotic features, anxiety disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, and cerebral palsy. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/25, revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #78 scored seven on the Resident Mood interview, which indicated the resident had mild depressive symptoms. The MDS revealed Resident #78 exhibited no behavioral symptoms during the 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.

Based on observation, interview, record review, and facility policy review, the facility failed to develop individualized resident-centered care plans with measurable objectives for two (#3 and #61) of 49 residents whose care plans were reviewed. The facility census was 71. Findings include: 1. An admission Record revealed the facility admitted Resident #3 on 07/12/24. According to the admission Record, Resident #3 had a medical history that included diagnoses of cerebral infarction (stroke) and osteoarthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/25, revealed Resident #3 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated Resident #3 had no rejection of care. The MDS indicated Resident #3 had functional limitation in range of motion with impairment on one upper extremity and one lower extremity. The MDS revealed Resident #3 was dependent on staff for completion of all activities of daily living (ADLs),…

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 interview, observation, record review, and facility policy review, the facility failed to trim and clean the fingernails for one (#8) of three residents reviewed for activities of daily living (ADLs). The facility census was 71. Findings include:An admission Record revealed the facility admitted Resident #8 on 12/22/09 and most recently readmitted the resident on 05/29/21. According to the admission Record, the resident had a medical history that included multiple sclerosis, type II diabetes mellitus, the need for assistance with personal care, and a contracture of the left hand. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/25, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #8 was dependent upon staff for the completion of personal hygiene. Resident #8's Care Plan Report, included a focus area initiated 10/23/23, that indicated Resident #8 had a deficit in self-care related to multiple sclerosis. An 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.

Based on interview, observation, record review, and facility policy review, the facility failed to place a splint or handroll into residents contracted hands as ordered by the physician. This affected two (#3 #8) of three residents reviewed for contractures. The facility census was 71.Findings include: 1. An admission Record revealed the facility admitted Resident #3 on 07/12/24. According to the admission Record, Resident #3 had a medical history that included cerebral infarction (stroke) and osteoarthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/25, revealed Resident #3 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated Resident #3 had not rejected care during the assessment's lookback period. The MDS indicated the resident had functional limitations in range of motion on one upper extremity and one lower extremity. The MDS revealed Resident #3 was dependent on staff for completion of all activities 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, interview, record review, facility policy review, and product operation manuals, the facility failed to ensure resident weight settings were correct on low air loss mattresses. This affected two (#2 and #57) of two residents reviewed for pressure ulcer management. The facility census was 71.Findings include:1. An admission Record indicated the facility originally admitted Resident #2 on 07/29/15 and readmitted the resident on 03/06/23. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure and unspecified head injury. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/25, revealed Resident #2 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated Resident #2 was dependent with activities of daily living (ADLs) and had functional limitations of both upper and lower extremities. The MDS indicated Resident #2 was at risk for pressure…

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 facility policy review, record review, observation, and interview, the facility failed to ensure residents did not retain their own lighters according to the facility policy. This affected three (#61, #5, and #58) of four residents reviewed for smoking. The facility census was 71.Findings include: 1. An admission Record revealed the facility admitted Resident #61 on 09/04/25. According to the admission Record, the resident had a medical history that included diagnoses of acute chronic diastolic (congestive) heart failure; chronic obstructive pulmonary disease, unspecified; and unspecified asthma, uncomplicated. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/11/25, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #61's Care Plan Report revealed no information about the resident smoking. Resident #61's Smoking Assessment, dated 12/04/25, indicated that Resident #61 did not have…

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 manufacturer guidelines, observation, and interview, the facility failed to ensure staff sanitized a blood glucose monitor after checking a resident's blood sugar and before placing the blood glucose monitor into the medication cart for further use. This affected one (#8) of two residents observed who had their blood sugar checked during medication administration. The facility census was 71.Findings include:An admission Record revealed the facility admitted Resident #8 on 12/22/09 and most recently readmitted the resident on 05/29/21. According to the admission Record, the resident had a medical history that included a diagnosis of type II diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/25, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident had an active diagnosis of diabetes mellitus. Resident #8's Care Plan Report revealed a focus statement initiated 09/23/14, that indicated 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, staff interviews, review of the Ohio Department of Health (ODH) Gateway Application, review of a facility timeline, review of a Narcotic Administration Sheet and policy review, the facility failed to report an allegation of misappropriation to the State Agency. This affected one (#79) out of three residents reviewed for misappropriation. The facility census was 77. Findings include: Review of the medical record for Resident #79 revealed an admission date of 03/05/25 with diagnoses of osteomyelitis, type 2 diabetes mellitus without complications, neoplasm of unspecified behavior of respiratory system, retropharyngeal and parapharyngeal abscess, personal history of malignant neoplasm of larynx, and tracheostomy status. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact, did not eat anything by mouth, and was independent with all activities of daily living. Review of the physician orders revealed an order dated 06/30/25 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, observations, staff interviews and policy review, the facility failed to ensure tracheostomy (trach) supplies were available in accordance with the care plan and facility policy. This affected one (#77) out of three residents reviewed for trach care and services. The facility census was 77. Finding include: Review of the medical record for Resident #77 revealed an admission date of 03/06/23 with diagnoses of anoxic brain damage, epilepsy, unspecified, intractable, without status epilepticus, chronic obstructive pulmonary disease, and acute on chronic systolic (congestive) heart failure. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired, was dependent on staff for all activities of daily living, and resident had a trach. Review of the care plan dated 03/07/23 revealed a care plan for trach related to impaired breathing mechanics injury with interventions of keep extra trach tube and obturator at bedside. If tube is coughed…

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 ensure food items were properly stored. This had the potential to affect all residents, except two (#29 and #80) residents identified by the facility as receiving no nutrition from the kitchen. The facility census was 82. Findings include: Observation on 01/23/25 at 9:10 A.M. of the walk-in freezer revealed a package of opened and undated hot dogs on the top shelf. The hotdog packaging was not sealed, leaving the hot dogs exposed to the freezer elements. Further observation revealed a package of pepperoni, not in the original packaging, which was unlabeled and undated. Observation on 01/23/25 at 9:20 A.M. of the walk-in refrigerator revealed an opened package of shredded cheese, two opened packages of bologna, and sliced turkey wrapped in pan liner paper. Each of the items were undated. Interview on 01/23/25 at 9:35 A.M. with Dietary Manager (DM) #63 verified the hot dogs in the walk-in freezer were not properly sealed or dated and the pepperoni was unlabeled and undated. DM #63 confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a transportation communication log, resident and staff interviews, and facility policy review, the facility failed to provide proper and timely care/services to ensure a medical procedure was completed. This affected one (#9) of three residents reviewed for outside medical appointments. The census was 83. Findings Include: Resident #9 was admitted to the facility on [DATE]. His diagnoses were rhabdomylosis, congestive heart failure, alcohol dependence, alcoholic hepatitis, alcohol abuse, hepatic encephalopathy, dementia, depression, hypertension, and tobacco use. Review of Resident #9's minimum data set (MDS) assessment, dated 10/29/24, revealed he had a mild cognitive impairment. Review of Resident #9's Central Appointment Communication Sheet, dated 10/18/24, revealed he was to have an orthopedic appointment on 11/20/24. Handwritten on this form, it stated, rescheduled per [physician], awaiting cardiac clearance. There was no date as to when this order was given by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a transportation communication log and staff interview, the facility failed to maintain complete resident medical records regarding outside medical appointments. This affected three (#9, #20, and #35) of three residents reviewed for outside medical appointments. The census was 83. Findings Include: 1. Resident #9 was admitted to the facility on [DATE]. His diagnoses were rhabdomylosis, congestive heart failure, alcohol dependence, alcoholic hepatitis, alcohol abuse, hepatic encephalopathy, dementia, depression, hypertension, and tobacco use. Review of Resident #9's minimum data set (MDS) assessment, dated 10/29/24, revealed he had a mild cognitive impairment. Review of Resident #9's Central Appointment Communication Sheet, dated 10/18/24, revealed he was to have an orthopedic appointment on 11/20/24. Handwritten on this form, it stated, rescheduled per [physician], awaiting cardiac clearance. There was no date as to when this order was given by the physician. Also, there…

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 administer a medication as ordered. This affected one (#3) of three residents reviewed for medication administration. The census was 75. Findings include: Review of Resident #3's medical record revealed an admission date of 09/12/24. Diagnoses listed included psychoactive substance abuse, obesity, osteomyelitis, pulmonary embolism, and attention-deficit hyperactivity disorder. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. Review of physician orders revealed an order dated 09/12/24 for Ertapenem Sodium Reconstituted (antibiotic) one gram. Use one gram intravenously (IV) every 24 hours for infection until 10/29/24. Review of medication administration records (MAR) revealed Ertapenem Sodium Reconstituted one gram (IV) was not documented as being administered on 09/18/24, 09/27/24, 10/02/24, 10/04/24, 10/08/24, 10/10/24, 10/16/24, and 10/17/24. Interview with the Director 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, staff interview, and review of the facility policy, the facility failed to ensure residents received their medications as ordered. This affected one (Resident #64) of three residents reviewed for medication administration. The facility census was 61. Findings include: Review of the medical record for Resident #64's revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, history of gangrene of the right foot, peripheral vascular disease, and essential hypertension. Review of the November 2023 physician orders for Resident #64 revealed orders for Ampicillin and Sulbactam (antibiotic) 3 grams (gm) intravenously every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. related to gangrene of right foot. Review of the Medication Administration Record (MAR) for November 2023 for Resident #64 revealed the resident had not received the ordered antibiotic, Ampicillin and Sulbactam 3 gm intravenously on 11/02/23 at 6:00…

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. This affected one (first floor) of two medication rooms observed during the survey and had the potential to affect all residents residing in the facility. The facility failed to ensure medication were labeled, dated and stored appropriately in the medication carts. This affected one (200 hall) of two medication carts reviewed. Facility census was 66. Findings include: Observation and interview on 07/12/22 at 12:22 P.M. of the emergency medications stored in the first floor medication storage room revealed there were greater then 50 different expired medications. The dates varied from 03/15/22 to 07/05/22. This was verified with Assistant Director of Nursing (ADON) #131 at the time of observation. The facility confirmed the emergency medications could be utilized for any resident residing in the facility. Observation and interview on 07/12/22 at 11:08 AM of the 200 hall medication cart with Licensed Practical Nurse (LPN) #210 in the top drawer of the medication cart…

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. Observation of staff members upon entrance to the facility on [DATE] at 8:00 A.M. revealed no staff members were wearing eye protection while in resident care areas. Interview with Licensed Practical Nurse (LPN) #240 on 07/11/22 at 8:36 A.M. confirmed she was not wearing any eye protection while caring for residents. LPN #240 stated she was told she was not required to wear any. Interview with State Tested Nursing Assistant (STNA) #152 on 07/11/22 at 10:07 A.M. confirmed she was not wearing any eye protection. STNA #152 stated eye protection was not required, just facemask's. During in interview on 07/11/22 at 10:48 A.M. Regional Director of Clinical Services (RDCS) #250 confirmed staff members were not currently wearing any eye protection in the facility. RDCS #250 stated that staff were only required to wear eye protection if the county level was red, and currently the county was yellow. RDCS #250 stated she called the county health department every Monday to confirm the level. Review of the CDC website…

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, observations, staff and family interviews and policy review, facility failed to inform resident's, their representatives and families of positive Coronavirus Disease 2019 (COVID-19) cases in the facility. This had the potential to affect all 66 residents residing in the facility. Facility census was 66. Findings include Observation on 07/13/22 at 8:30 A.M. revealed front desk staff did not update visitors upon entrance to the facility of the COVID-19 outbreak. No signs were posted around the entrance to the facility regarding a COVID-19 outbreak. Interview on 07/13/22 at 2:20 P.M. with Assistant Director of Nursing (ADON) #131 revealed facility notifies residents and family of COVID-19 status in the facility by in person updates for residents that are their own decision makers and phone calls to families and guardians. ADON #131 revealed on the evening on 07/12/22 around 9:00 P.M. outbreak testing was done due to a resident testing positive for COVID-19. By the time outbreak testing was completed nine residents on the memory care unit had tested positive 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 observations, staff interview, and policy review, the facility failed to ensure all items stored in the refrigerator and freezer were properly labeled. This had the potential to affect 64 out of 66 residents residing in the facility as two residents (#32 and #60) do not consume food from the kitchen. The facility census was 66. Findings include: Observations on 07/11/22 from 8:38 A.M. to 8:43 A.M. revealed undated waffles, angel food cake, vanilla ice cream, English muffins, and breadsticks in the freezer. There was an undated metal container filled with hot dogs and covered with plastic wrap as well as undated [NAME] slaw, sandwiches, shredded cheese, lunch meat, jelly, and barbeque sauce located in the refrigerator. Interviews on 07/11/22 from 8:38 A.M. to 8:43 A.M. with Dietary Manager #175 confirmed the undated items in the freezer and refrigerator. The facility confirmed 64 out of 66 residents receive their meals from the kitchen and there are two (#32 and #60) residents who do not receive the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, facility failed to ensure the influenza (flu) and pneumonia vaccinations were offered and provided to residents. This affected four (#14, #21, #52, and #54) of five residents reviewed for immunizations. Facility census was 66. Findings include 1. Review of the medical record for the Resident #14 revealed an admission date of 02/17/22. Diagnoses included repeated falls, diabetes, chronic kidney disease, and intellectual disabilities. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had significant cognitive impairment with a brief interview for mental status (BIMS) of six out of 15 and required extensive assistance of one staff member for bed mobility and transfers. Further review of Resident #14's record revealed there was no evidence of consents for the flu vaccine or updated pneumonia vaccine. Review of the immunology record revealed Resident #14 had received the pneumonia vaccinations on 01/05/2011…

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, resident and representative interviews and policy review, the facility failed to ensure residents and families were invited to attend interdisciplinary care conferences. This affected one (#53) of five residents reviewed for care plans and care conferences. Facility census was 66. Findings include Review of the medical record for the Resident #53 revealed an admission date of 07/24/20. Diagnoses included demyelinating disease of the central nervous system, sepsis, urinary tract infection, bacteremia, respiratory failure with hypoxia, multiple sclerosis, kidney failure, paranoid schizophrenia, muscle weakness, repeated falls and traumatic brain injury. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required extensive assistance of two staff members for bed mobility and transfers. Review of care conference meeting dated 07/23/21, 10/05/21,…

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 Medicare beneficiary notice letters, and staff interview, the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN), as required to residents when their Medicare Part A Services were ending. This affected two (#11 and #365) of three residents reviewed for Medicare beneficiary notice letters. The census was 66. Findings include: 1. Review of Resident #11's medical record revealed an admission date of 07/27/16. Diagnoses listed included hypertension, diabetes mellitus, and muscle weakness. Review of Notice of Medicare Non-Coverage (NOMNC) dated 05/10/22 revealed Medicare part A Services would end on 05/12/22. Further review of Resident #11's medical record revealed she remain in the facility after 05/12/22 and currently resided in the facility. There was no documentation of a SNFABN being issued to Resident #11. 2. Review of Resident #365's medical record revealed an admission date of 11/14/17. Diagnoses listed included hypertension, type II diabetes mellitus, and muscle weakness. Review of NOMNC 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, observation, and staff and resident interview, the facility failed to ensure a resident's bathroom and shower were in good condition. This affected one (#364) out of 19 resident reviewed in the sample. The census was 66. Findings include: Review of Resident #364 medical record revealed an admission date of 07/07/22. Diagnoses listed included burns to 30 to 39 percent of body, opioid dependence, traumatic [NAME] injury, and major depressive disorder. A Minimum Data Set (MDS) assessment had not yet been completed. Observation of Resident #364's bathroom on 07/14/22 at 11:25 A.M. revealed the floor outside of the shower was covered with a blanket and towels. The blanket and towels were wet. The right side bottom edge of the shower had an area with no rubber seal. Water was visible on the bathroom floor. The drain located in the center of the shower was not covered with a screen. A bath chair and bath supplies were in the shower. The flooring to the left of the toilet was peeling up…

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, staff interview, and policy review, the facility failed to ensure a resident on dialysis was monitored for signs and symptoms of infection. This affected one (#22) of one residents reviewed for dialysis. The facility census was 66. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/14/05. Diagnoses included venous insufficiency (chronic) peripheral, atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, hypertension, peripheral vascular disease, edema, type two diabetes mellitus without complications, legal blindness, major depressive disorder, unspecified dementia without behavioral disturbance, and chronic kidney disease stage 4. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/23/22, revealed Resident #22 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 00. Resident #22 was assessed to require extensive assistance for bed mobility, transfer, and dressing, supervision for eating, and was totally…

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 and Physician #210 interviews, the facility failed to ensure physician ordered laboratory (lab) values were obtained as physician ordered. This affected one (#4) of one residents reviewed for labs services. Facility census was 66. Findings include: Review of the medical record for the Resident #4 revealed an admission date of 10/06/11. Diagnoses included chronic obstructive pulmonary disease, Alzheimer's disease, dementia, psychosis, vascular disease, and malnutrition. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had significant cognitive impairment with a brief interview for mental status (BIMS) of seven out of 15 and required supervision assistance of one staff members for bed mobility and transfers. Review of pharmacy recommendation dated 05/28/22 revealed Resident #4 was receiving treatment with a HMG CoA reductase inhibitor medication to lower cholesterol. The Pharmacist requested a fasting lipid panel and liver function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of electronic mail (email) communication, staff interviews, and policy review, the facility failed to ensure residents had dental services arranged in a timely manner. This affected two (#43 and #44) out of three residents reviewed for dental services. The facility census was 66. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 10/20/16. Diagnoses included cerebral infarction, hypertension, rheumatoid arthritis, hydrocephalus, cholecystitis, major depressive disorder, and unspecified dementia with behavioral disturbance. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 06/13/22, revealed Resident #44 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15. Resident #44 was assessed to require extensive assistance for bed mobility and dressing, limited assistance for eating, and was totally dependent on staff for transfer, personal hygiene, and toileting.…

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 Coronavirus Disease 2019 (COVID-19) vaccinations were offered and provided to residents. This affected three (#14, #31, and #52) of five residents reviewed for immunization. Facility census was 66. Findings include: 1. Review of the medical record for the Resident #14 revealed an admission date of 02/17/22. Diagnoses included repeated falls, diabetes, chronic kidney disease, and intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had significant cognitive impairment with a brief interview for mental status (BIMS) of six out of 15 and required extensive assistance of one staff member for bed mobility and transfers. Review of Resident #14's record revealed no evidence of consents for the COVID-19 vaccine. Review of the immunology record revealed Resident #14 had no record of any COVID-19 vaccines. 2. Review of the medical record for the Resident #31…

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

Based on review of the facility's Water Management Plan and staff interview, the facility failed to implement it's Legionella prevention plan. This had the potential to affect all the residents of the facility. The census was 79. Findings include: Review of the facility's Water Management Plan dated 09/04/18 revealed the facility would complete water temperature checks monthly. Hot water was to be above 122 degrees Fahrenheit (F), cold water temperatures were to be below 68 F. Shower heads and hoses would be dismantled, cleaned, disinfected, and descaled quarterly. During an interview on 06/05/19 at 2:10 P.M. Maintenance Director (MD) #56 confirmed water checks were not being completed monthly for temperatures above 122 F or below 68 F, and that shower heads and hoses were not dismantled, cleaned, disinfected, and descaled quarterly. MD #56 was unable to provide any documentation of any water checks being completed or shower head maintenance per the facility's Water Management Plan.

Based on resident council meeting, resident and staff interviews, review of the local post office business hours, and facility policy review the facility failed to ensure mail was delivered on Saturdays. This affected six (#14, #15, #28, #41, #47, and #61) of six residents interviewed during resident council meeting and had the potential to affect all 79 residents in the facility. Facility census was 79. Findings include: During a resident council meeting held on 06/04/19 at 1:34 P.M., revealed Residents (#14, #15, #28, #41, #47, and #61) stated that no mail was delivered on Saturdays due to no one was in the front office to deliver the mail to the residents. Interview with Director of Activities (DA) #47 on 06/04/19 at 2:00 P.M., stated the postal service did deliver mail to the facility on Saturdays and the mail was held until Monday when staff was at work. Review of the local post office business hours revealed on Saturdays the post office was opened from 9:00 A.M. to 1:00 P.M. Review of facility policy titled Mail Delivery with no date revealed mail will be delivered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, and review of facility policy the facility failed to maintain residents' room environment in a safe and comfortable manner. This affected 10 rooms (100, 101, 102, 103, 104, 106, 108, 113, 114, and 115) out of 13 rooms on the 100 Hall. Facility census was 79. Findings include: 1. During initial tour and observation of the facility on 06/03/19 at 10:02 A.M., revealed a. room [ROOM NUMBER] had approximately four holes in the wall near the back and in the bathroom; exposing the drywall. The holes were approximately dime size. b. room [ROOM NUMBER] closet doors were off the hinges and the privacy curtains had about 10 brown colored stains that were approximately three to five inches. c. room [ROOM NUMBER]'s bathroom had approximately four holes on the wall that were each about the size of a dime. 2. Observations on 06/04/19 at 6:07 P.M., revealed rooms (103, 106, 108, 113, 114, and 115) had approximately four holes that were each about the size of a dime. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments. This affected two (#13 and #77) of 18 residents reviewed during the investigation stage of the annual survey. The facility census was 79. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 12/22/09 with diagnoses that included cognitive communication deficit, major depressive disorder, bipolar disorder, dementia with behavioral disturbance, and other mental disorders due to known physiological condition. Review of an annual MDS assessment dated [DATE] revealed Resident #13 was not coded as having a serious mental illness. Review of a pre-admission screening and annual resident review (PASARR) level 2 dated 12/21/09 revealed that Resident #13 was determined to have serious mental illness. MDS Nurse #49 confirmed during an interview on 06/05/19 at 11:47 A.M. that Resident #13 should have been coded as having a serious mental illness on the annual…

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 have resident's medication and/or treatment orders reviewed and signed by the physician. This affected three Resident's (#19, #38 and #42) reviewed during the investigation stage of the annual survey. The facility census was 79. Findings include: 1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebra infarction, muscle weakness, dysphagia, hemiplegia and hemiparesis of left side, type two diabetes, hypertension, dementia with behavioral disturbance, chronic obstructive pulmonary disease, heart disease, gastro-esophageal reflux disease, glaucoma, vertigo, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired with inattention, disorganized thinking, hallucinations, delusions, and other behavioral symptoms not directed towards others. Review of Section G-Functional 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, staff interview, and review of facility policy, the facility failed to securely store medications and/or dispose of outdated/undated medication. This had the potential to affect all 79 residents residing in the facility. Findings include: Observation conducted on [DATE] at 10:43 P.M. with Registered Nurse (RN) #11 revealed three cases of Betaseron Injections (for treatment of Multiple Sclerosis) were noted sitting on the counter in the unlocked chart room, and unattended by staff. Interview at the time of the observation with RN #11 verified the medication was left in the chart room and stated that was where they kept the cases of that medication for the resident. At that time, RN #11 removed the medication and put it inside the locked 100/200 hall medication room. The 100/200 hall medication room was observed and noted there were three bottles of Mineral Oil (for constipation) with an expiration date of 01/2019, one box of Bisacodyl suppositories (for constipation) with an expiration date…

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 and staff interview, the facility failed to maintain resident call lights in working order. This affected six Rooms # (301, 303, 304, 306, 308, and 310) of 13 rooms on the 300 hall. The facility census was 79. Findings include: Observation and interview conducted on 06/03/19 at 10:17 A.M. with Activities Assistant (AA) #28 revealed a resident in room [ROOM NUMBER] was requesting assistance, and upon hitting the call button, it was noted the light was not working. Further observation of the 300 hall rooms revealed lights in rooms 303, 304, 306, and 308 were not working, and rooms 301 A bed and 310 A bed were both noted with the push button broke off. AA #28 verified call lights not working and some push buttons were broken and stated it must have just happened because the lights were working. Observation and interview conducted on 06/06/19 at 2:05 P.M. with Maintenance Worker (MW) #77 verified lights in rooms 303, 304, 306, and 308 were all not working, and rooms 301 A bed and 310 A bed were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interviews, the facility failed to treat a resident in a dignified manner. This affected one Resident (#55) of two reviewed for dignity during the investigation stage of the annual survey. The facility census was 79. Findings include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including mental disorder due to known physiological condition, trichomoniasis, hypertension, benign neoplasm of skin, cardiomegaly, hyperlipidemia, nicotine dependence, dementia without behavioral disturbance, and paranoid schizophrenia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired with inattention, disorganized thinking, and delusional behaviors. Review of section G-Functional Status revealed the resident required extensive two-person assistance with bed mobility, total two-person assistance with transfer, walking did not occur, total one-person…

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 interviews and review of the facility policy, the facility failed to assess, monitor, and/or obtain orders for a resident's seatbelt. This affected one resident (#33) of one reviewed for restraints during the investigation stage of the annual survey. The facility census was 79. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, intellectual disabilities, anemia, gastro-esophageal reflux disease, insomnia, osteoporosis, dysphagia, and convulsions. Further review of the medical record was silent of verification of an assessment, physician order, care plan, and/or monitoring for the use of a seatbelt. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment with no noted behaviors. Review of section G-Functional Assessment revealed the resident required extensive one-person assistance with bed mobility,…

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 interview, the facility failed to update a resident's care plan. This affected one Resident (#64) of two reviewed for urinary catheters. The census was 79. Findings include: Review of Resident #64's medical record revealed and admission date of 07/21/18 with diagnoses that included prostatic endocarcinoma, chronic kidney disease, diabetes mellitus type II, cerebrovascular disease and hypertension. Review of a care plan dated 07/26/18 revealed Resident #64 has an indwelling urinary (Foley) catheter due to urinary obstruction. Observation and interview on 06/05/19 at 8:44 A.M. revealed Resident #64 did not have Foley catheter. Minimum Data Set (MDS) Nurse #49 confirmed during an interview on 06/05/19 at 10:03 A.M. that Resident #64 no longer had a Foley catheter and his care plan had not been updated. Unit Manager #76 during an interview on 06/06/19 at 12:45 P.M. confirmed Resident #64 no longer had a Foley catheter and that it had been removed 09/08/18.

Based on medical record review, observation, and resident and staff interviews, the facility failed to provide bathing assistance to residents who required assistance. This affected one (#127) of two residents reviewed for activities of daily living (ADL). The census was 79. Findings include: Review of the medical record for Resident #127 revealed an admission date of 05/23/19. Diagnoses included lumbago with sciatica right side, other intervertebral disc, degeneration lumbar region, muscle weakness, difficulty in walking not elsewhere, foot drop left foot, other irritable bowel syndrome, spondylosis cervical other cervical disc displacement unspecified cervical region, post-traumatic stress disorder, infantile idiopathic scoliosis, hypertension gastro-esophageal reflux disease without esophagitis and asthma. Review of admission Minimum Data Set (MDS) assessment, dated 05/30/19 revealed Resident #127 had intact cognition and required limited assistance for personal hygiene, transfer dressing and toileting. Interview on 06/03/19 at 10:53 A.M., Resident #127 reported she had not had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interviews, the facility failed to assess and/or monitor for continued use of a urinary catheter. This affected one Resident (#3) of two residents reviewed for urinary catheters during the investigation stage of the annual survey. The facility census was 79. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, heart disease, hypertension, and heart failure. Further review of the medical record was silent of diagnoses and/or rationale for use of a urinary catheter, physician assessment of the catheter, and/or assessments/attempts to discontinue its use. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Review of section G-functional status revealed the resident required supervision with eating, extensive one-person assistance with dressing, total one-person assistance with toileting,…

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 obtain a chest X-ray as ordered by a physician. This affected one Resident (#19) of one reviewed for respiratory care. The census was 79. Findings include: Review of Resident #19's medical record revealed an admission date of 04/24/17 with diagnoses that included muscle weakness, diabetes mellitus type II, chronic ischemic heart disease and hypertension. Further review of the medical record revealed a physician order dated 04/23/19 for a chest X-ray due to productive cough. Chest X-ray results were not found in Resident #19's medical record for 04/23/19. During an interview on 06/03/19 at 10:52 A.M. Resident #19 stated she had a cough for months. Resident #19 coughed up pale yellow phlegm during the interview. Unit Manager (UM) #76 during an interview on 06/06/19 at 10:40 A.M. confirmed Resident #19's chest X-ray was not completed as ordered on 04/23/19.

Based on medical record review, observation, and interview, the facility failed to appropriately assess a Resident #64's dialysis access. This affected one Resident (#64)of one reviewed for dialysis. The census was 79. Findings include: Review of Resident #64's medical record revealed and admission date of 07/21/18 with diagnoses that included prostatic endocarcinoma, chronic kidney disease, diabetes mellitus type II, cerebrovascular disease and hypertension. Further review revealed Resident #64 was receiving hemodialysis services from an outpatient dialysis facility. Resident #64 was receiving dialysis treatments through a dialysis catheter in his right upper chest. Review of progress notes dated 06/04/19 at 3:29 P.M. revealed that Registered Nurse (RN) #11 documented Resident #64 being assessed for bruit and thrill. An observation of RN #11 assessing Resident #64 for bruit and thrill was made on 06/05/19 at 10:17 A.M. RN # 11 palpated and listened with a stethoscope around Resident #64's dialysis catheter. During an interview at the time of the observation RN #11 confirmed she 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 medical record review and staff interview, the facility failed to ensure residents were was free of unnecessary medications. This affected two Residents (#11 and #42) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoes included abscess of the rectum and/or peri -rectal area type 2 diabetes mellitus without complications, urinary tract infection, pressure ulcer of unspecified buttock, obstructive sleep apnea syndrome, morbid severe obesity due to excess calorie, hypothalamic-pituitary insufficiency, dysphagia pharyngoesophageal phase, gastro-esophageal reflux disease without esophagitis and sepsis. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had intact cognition and required extensive assistance with activities of daily living. Review psychiatry notes with date of service on 04/01/19 revealed Resident #11 was prescribed Alprazolam 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 review of facility policy, the facility failed to obtain physician ordered labs for residents. This affected one Resident (#42) of five reviewed for unnecessary medications during the investigation stage of the annual survey. The facility census was 79. Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease, hypertension, myasthenia gravis, heart disease, cerebrovascular disease, hyperlipidemia, osteoarthritis, falls, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired with inattention, disorganized, and rejection of care behaviors noted. Review of Section G-Functional Status revealed the resident required extensive one-person assistance with bed mobility, eating, total one-person assistance with transfer, dressing,…

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.